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
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 2013 Apr 26];22:835-8. Available
from: http://www.ijdr.in/text.asp?2011/22/6/835/94680
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. [1]
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. [2]
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. [1],[3] 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. [3]

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].
Figure 1: Intraoral photograph showing ulcer in right maxillary
gingiva
Click here to view

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].
Figure 2: Photograph showing ulcerated gingiva
Click here to view

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].
Figure 3: Intraoral photograph showing palatal ulceration
Click here to view

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].

Figure 4: Chest radiograph showing no abnormality

Click here to view

Figure 5: Photomicrograph showing multinucleated giant cells

Click here to view

Figure 6: Photomicrograph showing acid fast bacilli

Click here to view

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. [4]
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. [5]
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. [6] 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. [6]
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. [6]
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. [6] 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. [7]
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.
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