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Table of Contents   
ORIGINAL RESEARCH  
Year : 2013  |  Volume : 24  |  Issue : 2  |  Page : 245-248
Prevalence of oral lesions in Brazilian patients with tuberculosis


1 Department of Clinic and Preventive Dentistry, Oral Medicine Unit, Federal University of Pernambuco, Brazil
2 Oral Medicine Unit, Eastman Dental Institute for Oral Health Care Sciences, University of London, London, United Kingdom

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Date of Submission05-Aug-2010
Date of Decision15-Jun-2011
Date of Acceptance27-Jan-2012
Date of Web Publication20-Aug-2013
 

   Abstract 

Background : Oral lesions of tuberculosis (TB) are rare and usually associated with the secondary form of the disease.
Aim : The aim of the present study was to determine the prevalence of oral lesions in a cohort of TB-infected individuals.
Materials and Methods : The study was carried out in two reference centers for the treatment of TB in Recife, Brazil. All patients treated for TB in the period from July 2008 to March 2009 were included in the study. The data was subjected to descriptive statistical analysis.
Results : One hundred and twenty-one patients were included in the study. A marked male prevalence was observed, with a male:female ratio of 6.12:1. HIV coinfection was a common event (33%). Head and neck lesions of TB were rare. Cervical node enlargement was observed in seven individuals (5.8%) and oral ulceration in one patient (0.8%).
Discussion : The low prevalence of oral lesions of TB is in accordance with other studies. Nodal involvement is the most common form of head and neck disease.
Conclusion : While TB may be a common accompanying feature of HIV disease, orofacial complications of TB are rare in individuals resident in northern Brazil.

Keywords: HIV infection, mouth diseases, oral tuberculosis, prevalence, scrofula

How to cite this article:
Santiago RA, Gueiros LA, Porter SR, Gomes VB, Ferrer I, Lećo JC. Prevalence of oral lesions in Brazilian patients with tuberculosis. Indian J Dent Res 2013;24:245-8

How to cite this URL:
Santiago RA, Gueiros LA, Porter SR, Gomes VB, Ferrer I, Lećo JC. Prevalence of oral lesions in Brazilian patients with tuberculosis. Indian J Dent Res [serial online] 2013 [cited 2020 May 31];24:245-8. Available from: http://www.ijdr.in/text.asp?2013/24/2/245/116698
Tuberculosis (TB) is a major infectious cause of death in adults and hence the World Health Organization (WHO) has declared a state of emergency since 1997. The last WHO report showed an expected incidence of 9.4 million cases of TB in 2008, approximately 139 cases for every 100000 individuals; this represents an increase of 100000 new cases over the incidence reported in 2007. [1] Interestingly, there seems to be a high rate of TB-HIV coinfection, with these patients accounting for nearly 28% of TB deaths. [2] Almost 95% of the individuals exposed to Mycobacterium tuberculosis are asymptomatic, only 5% developing clinically symptomatic disease. Primary disease is most often localized to the lungs but a few patients have disease that has spread to other organs or systems.

Extrapulmonary TB constitutes approximately 25% of TB lesions, and 10%-35% of these are found in the head and neck region. [3] However, primary extrapulmonary disease is uncommon and oral lesions are even rarer, constituting less than 1% of all primary head and neck cases. [4] Generally, primary oral TB is associated with ingestion of milk contaminated with Mycobacterium bovis by children and adolescents. [5] Secondary infection following pulmonary TB occurs either via an exogenous route, with infected sputum involving the crypts of the tonsils and the patient presenting with unilateral tonsillar enlargement, or via an endogenous route, with hematogenous spread from a pulmonary focus involving the germinal centers and the patient presenting with bilateral tonsillar enlargement. [3]

Usually, oral disease is observed as a painless ulcerated lesion in the palate, lips, or tongue, along with persistent cervical lymphadenopathy. [6] Autoinoculation can occur via contact of injured oral mucosa with infected sputum in patients with pulmonary TB. [7] Although most cases of oral TB present with a chronic ulcerative mucosal lesion, it may also present as a granuloma, osteomyelitis, or salivary gland disease. [8] The aim of the present study was to evaluate the prevalence of oral lesions in a cohort of TB-infected individuals in Recife, Brazil.


   Materials and Methods Top


Patients undergoing treatment for pulmonary TB in two reference centers for the treatment of TB in Recife (Hospital Correia Picanço and Hospital Otávio de Freitas) from July 2008 to March 2009 were considered eligible for inclusion. Both primary and secondary clinical presentations of TB were eligible for inclusion in this study. Both the hospitals are public sector institutions and cater mostly to low-income patients. All patients were interviewed immediately after their clinical consultation in a separate room of the hospital. Ethical clearance was given by the Research Comitee of Federal University of Pernambuco, under number131/08.

A well-experienced oral medicine specialist performed the clinical examination, including extraoral examination (assessment of cervical and submandibular lymph nodes) and intraoral examination. Clinical diagnosis of oral TB was confirmed by incisional biopsy under local anesthesia and microscopic analysis after hematoxylin and eosin staining and Ziehl-Neilsen staining. Clinical data regarding diagnosis, HIV infection, past medical history and previous adimission to the hospital. were retrieved from the files of each patient. The patients were classified as those having active untreated pulmonary TB, those with TB that had failed therapy, or those who had not completed therapy; patients were also categorized according to HIV status. Extrapulmonary presentations of TB were also considered. Descriptive analysis was performed to examine the distribution of the analyzed variables in the study population.


   Results Top


One hundred and twenty-one patients with diagnosis of TB were included in the study. There was a marked male predilection among our study subjects, with a male:Female ratio of 6.12:1. The mean age was 39.7 years (range: 18-69 years). Prior to the treatment, 92 patients (76%) had active untreated TB, 4 patients (3.3%) presented with recurrent pulmonary disease following completion of therapy, 4 patients (3.3%) were classified as having multidrug-resistant disease, and 21 patients (17.4%) had failed to complete their course of therapy. The HIV-positive group comprised 31 patients (25.61%), of whom 27 were males; all HIV-positive patients were on highly-active antiretroviral therapy (HAART).

Cervical and submandibular lymph node involvement was observed in seven patients (5.78%; five male and two female) as a single enlarged node. Of these, only one patient was HIV positive [Table 1]. No further evaluation of the nodes was performed in these patients. One patient had an ulcerated oral lesion due to TB. This patient was a 56-year-old female who presented with complaints of dysphagia and a painful lesion in the hard palate. She was HIV negative and did not show radiological evidence of pulmonary involvement. Neck palpation revealed enlarged right submandibular lymph nodes. Intraoral examination revealed a 4-cm diameter ulcerated lesion located in the left maxillary edentulous ridge and the adjacent hard and soft palate, with radiographic evidence of bone destruction. An incisional biopsy was performed under local anesthesia and microscopic diagnosis confirmed the clinical suspicion of TB.
Table 1: Prevalence of head and neck lesions in TB patients


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   Discussion Top


Cervical and submandibular lymphadenopathy, termed scrofula, is the most frequent manifestation of head and neck TB and can present as a single mass or as bilateral neck masses, usually affecting deep lymph nodes. Sometimes there may be associated supraclavicular and axillary node involvement. [9] After penetrating the respiratory tract, Mycobacterium tuberculosis can proliferate and establish itself in any organ though it especially favors the lungs. The main places of extrapulmonary implantation are those with good blood supply such as the renal and cerebral cortex, bones, pleura, and lymphatic system. Cervical node TB is the most common form of neck disease, accounting for up to 5% of the cervical lymphadenopathy. [3] The oral cavity accounts for 0.2%-1.5% of all cases of extrapulmonary TB, with involvement mostly being secondary to pulmonary TB. [10]

This study showed a low prevalence of head and neck TB (5.78%) and an even lower prevalence of oral TB. TB lymphadenitis affected the submandibular and cervical lymph nodes but no salivary gland disease was observed. One patient showed submandibular lymph nodes involvement, while others showed cervical lymphadenitis. We found that once the patients had been treated for enlarged lymph nodes at centers for infectious diseases, no additional clinical investigation was routinely performed when persistent neck masses were noted. Generally, extrapulmonary TB in the neck is found in the submental and submandibular lymph nodes as well as the salivary glands. [3],[9] Oral TB is only rarely seen, even among individuals with head and neck TB. [11],[12] Interrestingly, the mean age of the patients with tuberculous lymphadenitis in this study was lower than that reported in other studies (39.9 years). [9]

Although the clinical picture is variable, oral TB lesions are most often observed as a chronic ulcer with a granulating floor that eventually can be preceded by a vesicle or opalescent nodule. [5] These lesions usually present in the tongue, lips, and palate. [6],[8] Tongue lesions are often grayish-yellow, firm, and have ragged undermined edges; pain is not commonly reported. [9] On the other hand, palatal lesions may present as granulomas or ulcerations and are more prevalent in the hard palate. [7] In this series, the only patient with an oral lesion had a distinct clinical presentation, with an ulcerated painful lesion of the cheek extending to a granulomatous lesion on the palate.

The differential diagnosis of such tuberculous ulcers include a range of ulcerative diseases and conditions, such as squamous cell carcinoma, traumatic ulcer, aphthous stomatitis, syphilitic ulcer, actinomycosis, Wegener granulomatosis, sarcoidosis, leishmaniasis, zygomycosis, and Hansen disease. [13],[14] It is important to note that infectious oral ulcers may present a similar picture, leading to the need for a microscopic diagnosis, together with Mantoux test, acid-fast stains and culture, or molecular identification of the bacillus. [15] Actually, ulcerating lesions associated with palpable lymph nodes should raise a clinical suspicion of squamous cell carcinoma. However, when this situation is observed in children, adolescents, or patients not exposed to risk factors for carcinoma, the clinician should also consider TB as a reasonable differential diagnosis. [9]

Risk factors for oral TB are adequately identified. Possibly, high virulence of the infecting strain of M tuberculosis is a predisposing factor for oral involvement. [13] Some authors have suggested poor oral hygiene, local trauma, jaw fractures, periodontal disease, dental abscess, and periapical granulomas as local factors that predispose to oral TB. [6],[7],[14] Generally, immunosuppression is the main systemic predisposing factor for oral TB. [12] Tuberculous lesions, however, can also be seen in immunocompetent individuals, as observed in this study. [15] Interestingly, HIV coinfection was not an important risk factor for head and neck TB in this subset of patients.

HIV and TB coinfection constitutes a serious public health problem. An increasing number of TB cases in HIV-infected individuals have been notified. These cases can be associated with high morbidity and mortality. [2] It is estimated that one-third of the persons living with HIV infection are coinfected with TB. [16] This coinfection is so clinically relevant that current guidelines recommend that HIV testing be performed in every individuals diagnosed with TB; CD4 cell count is not a sufficient indicator of TB risk in HIV-positive individuals. [17],[18] Immunosuppressed patients are considered to be at high risk when there has been direct contact with a smear-positive case of pulmonary TB. [4] In our study, 31 patients were coinfected with TB and HIV and most of them had smear-positive pulmonary TB. However, seven patients presented with smear-negative TB. Only one patient with head and neck TB was coinfected with HIV. Overall, more than one-third of the sample was coinfected with HIV, which is similar to the WHO report. [2]

The management of TB in Brazil is standardized, varying according to the clinical form of disease. The choice of the treatment is based on the clinical type of disease, patient age, and history of previous treatment and its result. The treatment of extrapulmonary TB is usually for 6 months, except in the meningoencephalic type. In cases where the initial clinical response is not satisfactory, the treatment can be extended for a further 3 months. [19] Antituberculosis chemotherapy must be complemented by specific care in each type of extrapulmonary TB.

In summary, oral manifestations of the TB are rare and frequently associated with HIV infection. However, some cases are also observed in HIV-negative individuals. Although it is uncommon, TB must be considered among the differential diagnosis of chronic ulcerative lesions of the oral mucosa. Proper identification is of oral TB important not just for the patient but also for the dental team and for the community since the patient is a potential source of infection. Epidemiological data on oral TB are scarce and inconclusive and, therefore, new information must be provided.


   Acknowledgments Top


Funding: National Council for Scientifid and Technological Development (CNPq) and Coordination for the Improvement of high level personel (CAPES).

 
   References Top

1.World Health Organization. Global tuberculosis control: Epidemiology, strategy, financing: Who Report 2009. WHO, Switzerland.  Back to cited text no. 1
    
2.World Health Organization. Global tuberculosis control: A short update to the 2009 report. WHO, Switizerland, 2011.  Back to cited text no. 2
    
3.Vaid S, Lee YY, Rawat S, Luthra A, Shah D, Ahuja AT. Tuberculosis in the head and neck: A forgotten differential diagnosis. Clin Radiol 2010;65:73-81.  Back to cited text no. 3
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5.Ito FA, Andrade CR, Vargas PA, Jorge J, Lopes MA. Primary tuberculosis of the oral cavity. Oral Dis 2005;11:50-3.  Back to cited text no. 5
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12.Prasad KC, Sreedharan S, Chakravarthy Y, Prasad SC. Tuberculosis in the head and neck: Experience in India. J Laryngol Otol 2007;121:979-85.  Back to cited text no. 12
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13.Hale LT, Tucker CP. Head and neck manifestations of tuberculosis. Oral Maxillofac Surg Clin North Am 2008;20:635-42.  Back to cited text no. 13
    
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16.UNAIDS. Frequently asked questions about tuberculosis and HIV. Available at http://data.unaids.org/pub/factsheet/2006/tb_hiv_qa.pdf. Accessed January 10, 2010.  Back to cited text no. 16
    
17.Pillay T, Sturm AW, Khan M, Adhikari M, Moodley J, Connolly C, et al. Vertical transmission of Mycobacterium tuberculosis in KwaZulu Natal: Impact of HIV-1 coinfection. Int J Tuberc Lung Dis 2004;8:59-69.  Back to cited text no. 17
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19.Brazilian Health Ministry: Controle da Tuberculose: Uma Proposta de Integração Ensino-Serviço. Rio de Janeiro: Ministério da Saúde; 2005.  Back to cited text no. 19
    

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Correspondence Address:
Jair Carneiro Lećo
Department of Clinic and Preventive Dentistry, Oral Medicine Unit, Federal University of Pernambuco
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.116698

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