ORAL

TUBERCULOSI
S
D R . I S H I TA S I N G H A L
MDS FIRST YEAR
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CONTENT
• INTRODUCTION
• GLOBAL BURDEN OF THE DISEASE AND PREVALENCE
• RISK FACTORS RELATED TO TB
• ORAL MANIFESTATIONS OF TB
• ROLE OF AN ORAL PATHOLOGIST
• DIFFERENTIAL DIAGNOSIS OF ORAL LESIONS OF TUBERCULOSIS
• TREATMENT
• PRECAUTIONS
• CONCLUSION
• REFERENCES
INTRODUCTIO
N
• Tuberculosis is a disease characterized by granulomatous lesions
caused by Mycobacterium Tuberculosis. A German scientist Robert
Koch discovered the causative organism of TB in 1882.

• Since time immemorial, it has been a global health problem. TB

has shown a decline in its prevalence globally; however, it is still
highly prevalent in Asian countries.

• TB is usually overlooked in the differential diagnosis of oral lesions

as it is supposed to be a rare entity.

• Oral manifestations of TB occur either due to infected sputum or

due to hematogenous spread.
• In the ancient literature, TB has been described as kshay rog, phthisis, king's
evil, and white plague.

• In the Ayurveda, the treatment of TB has been described as spending time in

fresh air and good nutrition, which became the cornerstone of sanatorium
treatment. Sanatoria treatment remained the popular treatment modality
until 1943 when first antitubercular drug streptomycin was discovered.

• Later on, a number of other antitubercular drugs, such as thiacetazone, para-

aminosalicylic acid, pyrazinamide, and rifampicin, were discovered.

• With the extensive use of these antitubercular drugs, the problem of TB has
been controlled to a large extent, at least in the developed countries.
However, the resurgence of TB was also observed in the developed countries
since 1981 due to the increasing prevalence of human immunodeficiency
virus (HIV).

• Later on in 1993, World Health Organization declared TB as a global

emergency due to an increase in its prevalence, its association with HIV, and
increasing problem of drug resistance.
  GLOBAL BURDEN OF THE DISEASE AND PREVALENCE 
According to WHO (2016), approximately 10.4 million occurrences of
new cases are reported every year.

 BURDEN OF TB IN INDIA
In India 2.7 million new cases of TB are reported every year and about
4,23,000 deaths are been reported due to TB per year.

 Oral TB is considered as a rare disease and its prevalence ranges from

0.5% to 1% of all tubercular cases.
RISK FACTORS RELATED TO
TB
• Pulmonary TB (PTB) is a multibacillary disease and sputum of
these patients contains a larger number of bacilli. Oral TB is a
paucibacillary disease and concentration of acid-fast bacilli (AFB)
is significantly less in saliva.

• Local factors in the oral cavity, which may be contributing to

decreased susceptibility for the development of oral TB, are the
resistance of striated muscles to bacterial invasion, saprophytes,
and thickness of protective epithelial covering.

• Breach of the oral mucosa may also lead to the colonization of

bacteria.

• Poor oral hygiene, local trauma, leukoplakia, and irritation by

clove chewing can be considered as the attributing factors.
General conditions, such as overcrowding, addiction to alcohol or
ORAL MANIFESTATIONS OF TB
• Tuberculous lesions of the oral cavity do occur but are relatively uncommon.

• Oral TB lesions may be either primary or secondary in occurrence:

1. Primary lesions are uncommon, seen in younger patients often associated

with enlarged cervical lymph nodes.
2. Secondary oral TB usually coexists with pulmonary disease, may occur in all
age groups; however, middle-aged and older people are more likely involved.

• The most likely route of inoculation is the entry of organisms in the sputum
and, from there, entry into the mucosal tissue through a small break in the
surface.

• It is possible that the organisms may be carried to the oral tissues by a

hematogenous route, to be deposited in the submucosa, and subsequently to
proliferate and ulcerate the overlying mucosa.
 WHICH SITE IN THE ORAL
CAVITY???

The tongue is the most commonly affected site in various forms,

such as ulcers, nodule, fissures, plaques, or vesicles.

Buccal mucosa, gingiva, lips, palate, palatine tonsil, and floor of

the mouth can be also affected.

The salivary glands, tonsils, and uvula are also involved

frequently.
 How does it look like???

ULCERS

NODULES

TUBERCULAR FISSURES

TUBERCULAR PAPILLOMAS

TUBERCULOMA
• Primary oral TB usually involves gingival and presents as a diffuse,
hyperemic, nodular, or papillary proliferation of the gingival tissues.

• It is usually associated with regional lymphadenopathy.

• Primary gingival involvement is more common in children and

adolescents than in adults.

• It usually presents as a single painless indolent ulcer that 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 indurations and satellite lesions are commonly found.

• When oral TB arises as a primary lesion, an ulcer is the most prevalent

presentation generally developing along the lateral margins of the
tongue that ease against rough, sharp, or broken teeth or at the site of
other irritants.
TUBERCULO
US ULCER
ON TONGUE
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ULCER IN
THE BUCCAL
VESTIBULE
• Patients with oral tubercular lesions often have a history of pre-
existing trauma.

• Any area of chronic irritation or inflammation may favor localization

of the Mycobacterium associated with the disease.

• Deep tubercular ulcers of the tongue are typical in appearance with a

thick mucus 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, the midline, and base of the tongue.

• The clinical aspect and microscopic features confirmed the

appearance of tubercular ulcers as irregular, pale, and indolent with
inverted margins and granulations on the floor with sloughing tissue.
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(A)Extraoral photograph (D) Langhan's

shows enlarged cervical
cells containing
lymph node (B)Intra
orally photograph shows nuclei arranged in
an ulcer with well defined a horseshoe
margins on the right shaped pattern at
buccal mucosa covered by cell periphery
a yellow pseudo (arrow)
membrane (E) Several acid-
(C)Histopathological slide
fast bacilli in the
shows granulomatous
inflammation with sputum (Ziehl-
Langhan's giant cells and Neelsen stain).
focal caseous necrosis
Nanda KD, Mehta A, Marwaha M, Kalra M, Nanda J. A disguised tuberculosis in oral buccal mucosa. Dent Res J (Isfahan). 2011;8(3):154–159.
• The usual presentation of secondary TB is an irregular, superficial, or deep,
painful ulcer that 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.

• Occasional mucosal lesions show swelling, granular, modular, or fissured

lesions, but no obvious clinical ulcerations. TB may also involve the bone of
maxilla or mandible.

• One common mode of entry for the microorganism is into an area of periapical
inflammation by way of the bloodstream.

• It is also possible that these microorganisms may enter the periapical tissues
by direct immigration through the pulp chamber and root canal of a tooth with
an open cavity.

• The lesion produced is essentially a tuberculous periapical granuloma or

tuberculoma; diffuse involvement of the maxilla or the mandible may also
occur, usually by hematogenous spread of the infection, but sometimes by
direct extension or even after tooth extraction. Tuberculous osteomyelitis
frequently occurs in the later stages of the disease and has an unfavourable
prognosis.
 Click icon to add picture

Krawiecka E, Szponar E. Tuberculosis of the oral cavity: an uncommon but still a live issue. Postepy Dermatol Alergol. 2015;32(4):302–306.
ROLE OF AN ORAL
PATHOLOGIST
• While evaluating a chronic, indurated ulcer, clinicians should consider the
differential diagnosis of the infectious processes, such as primary syphilis,
deep fungal diseases, and non-infectious processes, such as chronic
traumatic ulcer and squamous cell carcinoma.

• Oral ulcer should further be evaluated by excisional biopsy and its

histopathological examination, AFB smear microscopy, AFB culture,
bacterial, and fungal culture, etc.

• Due to the paucity of AFB in the oral lesions, the sensitivity of AFB
examination is very low. In various studies, AFB smear positivity in a
various biopsy specimen of the oral lesion has been found around 7.8%.

• Typically, histopathology of the biopsy specimen shows a classical

caseating granuloma with central necrosis and is surrounded by epithelioid
cells, Langhan’s type of giant cells, and lymphocytes infiltration.
• However, in immunocompromised conditions such as acquired
immunodeficiency syndrome, there may be a noncaseating granuloma.

• A biopsy of an oral lesion is confirmatory but in the majority of the cases, a

single biopsy may not suffice because the granulomatous changes may not
be evident in early lesions.

• Sometimes repeated biopsies may be required and fine needle aspiration

cytology may also be tried if a biopsy is not possible. Mantoux skin test and
chest X-ray should be done to rule out the systemic TB.

• In case of diagnostic dilemma correlation of history, the clinical and

radiological examination should be done.

• Laboratory confirmation and thorough histopathological examination are

most essential for the diagnosis, with the culture of microorganisms taken
as the absolute proof of the disease.

• However, molecular tests such as line probe assay, nucleic acid amplification
test, and polymerase chain reaction, and microbiological tests such as
culture, mycobacterial growth indicator tube, and BACTEC are considered to
be the best tools for the diagnosis of TB.
DIFFERENTIAL DIAGNOSIS OF
ORAL LESIONS OF TB
• Oral lesions of TB are nonspecific in their clinical presentation and
often are overlooked in differential diagnosis, especially when oral
lesions are present before systemic symptoms become apparent.
Hence, doctors and dentists should be aware of the oral lesions of
TB and should consider them in the differential diagnosis of
suspicious oral ulcers.

• The aphthous ulcers, traumatic ulcers, syphilitic ulcers, and

malignancy, including primary squamous cell carcinoma,
lymphoma, and metastases are the differential diagnosis of the
tubercular ulcer of the oral cavity. As reported earlier, the most
likely clinical diagnosis is that of squamous cell carcinoma, in
which biopsy is mandatory.

• It is most likely that TB is only considered when the histological

specimen reveals a granulomatous lesion. This would then lead to
Slide title 29

Krawiecka E, Szponar E. Tuberculosis of the oral cavity: an uncommon but still a live issue. Postepy Dermatol Alergol. 2015;32(4):302–306.
TREATMENT
• The treatment of oral TB lesions is identical as systemic TB.

• Currently, the most effective regimens require a combination of 4 drugs

[isoniazid (INH), rifampicin (RIF), pyrazinamide (PZA), and ethambutol
(ETO)] administered daily for the first 2 months, followed by an
additional 4 months with 3 drugs (INH, RIF and ethambutol).

• The difficulty of this regimen prompted the WHO to launch a new global
strategy for TB control known as “Directly Observed Therapy, Short
course” (DOTS) in 1997. The central component of this strategy is a
direct observation by trained personnel, which secures both patient
compliance with the drug regimen and decreases the likelihood of drug
resistance.

• The management of TB is strenuous because of the two primary factors:

persistence and resistance.
• In spite of the fact that antibiotics are accessible, Mtb is extremely persistent,
possibly because the bacterium encourages chronic inflammation that
sequesters it inside the tissues, defending it against drug exposure.

• Thus, drug treatment must be extended to completely damage the bacterium

and prevent relapse.

• Drug resistance is the result of genetic mutations that cause a heritable loss
of drug susceptibility. Even though resistance to a single drug does not render
therapy unsuccessful, multi drug resistant strains make TB much more
expensive and difficult to treat.

• For this reason, they require newer and more effective drugs that achieve
multiple goals in improving TB controls that are imperative. There are two
types of resistance commonly observed in the context of TB:

1. Multidrug resistant TB (MDR) is described as mtb resistant to the most

effective first-line anti-tb drugs, isoniazid, and rifampicin

2. Extensively drug resistant (XDR) has additional multidrug resistance to the

most potent second-line agents, injectable drugs (aminoglycosides and/or
cyclic polypeptides-capreomycin, amikacin, and kanamycin), and
fluoroquinolones.
Slide title 29

Pai M. Promoting affordable and quality tuberculosis testing in India. J Lab Physicians. 2013;5(1):1–4.
PRECAUTIONS
• Clinical dental practice suffers from the vulnerability for transmission of
miscellaneous infections from patient to dentist, patient to patient, as
well as dentist to patient due to close proximity to the nasal and oral
cavities of the patient.

• Thus, a barrier should be generated to inhibit the transmission of

infections and to perform the clinical procedures secure from the threat
of cross infections.

• A thorough history of TB should prompt the dental practitioner to

recognize whether the person is an active case under treatment, the
active case without treatment, or formerly infected but presently disease
free.

• The nontreated active cases stand maximum risk to the dental healthcare
personnel.
• Dental healthcare professionals are at the uniform risk of getting
exposed to TB by the means of splatter, aerosols, or infected
blood. As various severe diseases are air-borne, blood-borne, or
can extend through the contact of other body fluids, and it is not
possible to know which certain patients are infected, so it is
pertinent to avoid direct contact with body fluids, blood, and
mucous membranes. Dental treatment for those with active TB
should be restricted to urgent and necessary procedures.

• High levels of operatory disinfection and instrument sterilization

should be provided. For recognized active TB patients, TB isolation
rooms that are properly equipped rooms with functional air
evacuation, negatively pressured correlative to the corridors, with
air either debilitated to the outside or HEPA filtered if recirculation
is mandatory, with high volume suction are designated for
carrying out any procedure to reduce the aerosol production.
Portable suction should be eluded as they recirculate air. Rubber
dams can be accustomed to minimize aerosol contact,
nevertheless if coughing occurs it should not be used.

• Proper sterilization procedures, personal protective gears, and

 • Ram Hari et al (2012) stated that Oral tubercular lesions are rare,
difficult to diagnose and pose a potential infectious hazard to
dental personnel engaged in treatment. An oral ulcer mimicking
squamous cell carcinoma of buccal mucosa must be considered for
being tubercular if biopsy of the lesion does not show a definitive
Ram H, Kumar S, Mehrotra S, Mohommad S. Tubercular ulcer: mimicking squamous cell carcinoma of buccal mucosa. J Maxillofac Oral Surg.
evidence of malignancy. 2012;11(1):105–108.

• Jain P et al (2014) stated that oral tubercular lesions can be either,

primary or, secondary to pulmonary tuberculosis, with secondary
lesions being more common. Most common sites for these lesions
are tongue, gingiva, floor of the mouth, buccal mucosa. Dorsum of
the tongue is most favourable site with these lesions appearing as
Jain P, Jain I. Oral Manifestations of Tuberculosis: Step towards Early Diagnosis. J Clin Diagn Res. 2014;8(12):ZE18–ZE21.
a stellate ulcer. It can also present on the tongue as macroglossia,
around upper aero digestive tract as parotitis, intra-osseous
lesions, preauricular swelling and trismus, tracheitis and
laryngitis.
CONCLUSION
• Oral tubercular lesions are rare, difficult to diagnose, and pose a
potential infectious hazard to dental personnel engaged in the
treatment.

• So, each and every persistent and atypical oral lesion must be
examined carefully to intercept and prevent the disease early.

• Intercepting the disease early will advance the morbidity and

mortality of the patients.

• So, it becomes the responsibility of the dentist to include TB in the

differential diagnosis of suspicious oral lesions to avoid delay in
the treatment of this disease.
REFERENCES
1. Nanda KD, Mehta A, Marwaha M, Kalra M, Nanda J. A disguised tuberculosis in oral
buccal mucosa. Dent Res J (Isfahan). 2011;8(3):154–159.

2. Krawiecka E, Szponar E. Tuberculosis of the oral cavity: an uncommon but still a

live issue. Postepy Dermatol Alergol. 2015;32(4):302–306.

3. Pai M. Promoting affordable and quality tuberculosis testing in India. J Lab

Physicians. 2013;5(1):1–4.

4. Ram H, Kumar S, Mehrotra S, Mohommad S. Tubercular ulcer: mimicking squamous

cell carcinoma of buccal mucosa. J Maxillofac Oral Surg. 2012;11(1):105–108.

5. Jain P, Jain I. Oral Manifestations of Tuberculosis: Step towards Early Diagnosis. J

Clin Diagn Res. 2014;8(12):ZE18–ZE21.
THANKYOU