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opic 152: Tuberculosis.

The etiology, pathogenesis, clinical manifestations on the oral mucous


membrane, diagnosis. Treatment and prevention. The tactics of dentist.
Questions for the control of students' knowledge.
1. Etiology and pathogenesis of tuberculosis. Clinical forms.
2. Manifestations in the oral cavity of lupus, ulcerative-miliary tuberculosis, kollikvativnogo
tuberculosis.
3. Diagnosis of tuberculosis.
4. Differential diagnosis of tuberculosis.
5. Treatment, prevention. The tactics of dentist.
Tuberculosis - a chronic infectious disease that is caused by Mycobacterium tuberculosis (Koch's
bacillus). It enters in the oral mucosa by hematogenic, lymphatic or exogenous (droplet or alimentary)
way, causing the primary and secondary manifestations of infection.
On the OMM tuberculosis manifests itself mainly secondary in 1% of patients in the form of
lupus, milliarno - ulcerative tuberculosis and very rare - a collective tuberculosis (scrofuloderme).
Primary tuberculosis of OMM and lips hardly occurs due to the fact that OMM is a poor ground
for bacilli. Development of the primary tuberculosis complex possible the children's place of introduction
of the pathogen: after 8-30 days (the incubation period), there is a painful ulcer size 10-15 mm with saped
jagged edges and dirty gray bottom. It is accompanied by lymphadenitis. Lymph nodes at the same time
can fester and opened. After 3-4 weeks the ulcer gradually disappears without treatment.
Lupus among TB disease of the oral mucosa and lips are the most common, persistent, prone to
relapses, chronic ongoing illness. The favorite localization of lupus is a face, which affected in about 75%
of patients.
The primary element in lupus is a tubercle (lyupoma), which is limited at the beginning of the
flat, pinhead-sized red or yellow-red soft painless education, prone to peripheral growth and merger with
neighboring elements. In this form shallow ulcers with soft saped maloboleznennymi uneven edges,
covered with bright red or yellow-red papillomatose like strowberry growths, easily bleeding when
touched.
At the clinical course tuberculous lupus passes infiltrative, papulose, ulcer and scar stage. From
skin lupus process can spread to the vermillion border of the upper lip and less often on the mucous of
gums in the front teeth of the upper jaw, the hard and soft palate, cheeks. Sometimes the process is
localized only on the red border.
For the lupoma diagnosis used two methods of research: diascopy and probbing. At diascopy
lupoma's consider by normal glass slide. By a pressure of the glass on the skin and the red border of lips
its bled out and take the form of "apple jelly." The second diagnostic method pressing by probe for
lupoma with easy probe fails (Pospelov phenomenon).
The regional lymph nodes are increased in lupus, become dense, knitted together into packages.
Pirke reaction is usually positive. Koch's bacillus is rarely defined.
Lupus is differentiated with papulose lesions in tertiary syphilis (where dense lumps and never
formed on the scars, Pospelov negative symptom), leprosy and lupus erythematosus. Recent notable for
the absence lupoma, characterized by the presence of bright erythema, gentle hyperkeratosis and scar
atrophy.
Milliarno-ulcerative tuberculosis. Initially, the OMM appears grayish-yellow or reddish point,
slightly raised above the surrounding tissue formation, which is a micro-abscesses, which is preceded by
tubercle. This stage of the disease as quickly gives way to stomach what to observe the primary elements
is usually not possible. Initially formed spot ulcers that quickly grow and merge into ulcers with diameter
up to 2.5 mm. These ulcers are shallow, irregularly shaped, their edges eroded, saped, soft. Ulcers sharply
painful. The bottom and the edge of ulcers are grained due to the nature tubercles covered with yellowgray plaque. Tissue surrounding the ulcer, swollen, with small abscesses (grain Trela). In the language
and transitional folds ulcers have a slit-like appearance with saped edges. Lymph nodes in the course of
the process are condensed, increase and become painful.
Doing diagnostics of milliarno-ulcerative tuberculosis is very important to assess the general
condition of the patient (fatigue, weight loss, pale skin, low-grade fever, night sweats). Pirke intradermal
test is often negative because of lower reactivity, but often possible to identify mycobacteria from the

surface of ulcers. Differentiate milliarno-ulcerative tuberculosis OMM with traumatic dekubitalnoy,


trophic ulcer, with gummy syphilides, Vincent's stomatitis, OMM cancer, tuberculosis lupus. The last one
is characterized by lupomes, a positive Pirke's reaction and presents of mycobacteria tuberculosis in the
discharge of ulcers.
Kollicvative tuberculosis (or skrofuloderme) on OMM is very rare, mainly in children and is
characterized by formation in the deeper layers of the mucous nodes. These nodes are gradually soften
and ulcerate, a small quantity of pus mixed with blood and pieces of necrotic tissue. The resulting ulcer
has an irregular shape, soft, with ulcerated cankered little painful edge, the bottom of it is covered with
sluggish granulation. When scarring produced uneven, "shaggy" scars. Skrofuloderme on OMM has some
similarities with syphiloma, actinomycosis, a cancerous tumor.
The treatment of tuberculous lesions of OMM dentist do on the against the overall treatment
assigned by phthisiatrician. Rehabilitation of the oral cavity, eliminating the traumatic factors are a
prerequisite for the local treatment of tuberculous lesions of OMM. Apply antiseptic, nekrolitic funds,
specific anti-TB drugs, painkillers and keratoplasty.
7. Practical skills of the topic:
1. Conducting a clinical examination of the patient with tuberculosis: trustee contact with patients, special
attention to the complaints, not only from the mouth, but also from the organs and systems; determine
anamnesis of disease, personal history to determine possible exposure routes, with an objective study, pay
attention to the body temperature, blood pressure, pulse, state of the lymph nodes, skin color and the
presence of lesions on the skin. In the mouth identify the presence of elements of defeat. Conduct
diascopy (checking for the phenomenon of "apple jelly" characteristic of lupus), the sample probe (probe
Pospelov). By pressing a glass slide on the skin or the red border of lips dehematize diseased tissue and
lyupomy as a yellow-brown nodes are clearly visible (reminiscent of apple jelly), and a pressure-sensitive
tip on the mound pugotovchatym probe falls into lyupoma probe of Pospelov, or a symptom of falling
through the probe.
3.Material capture for cytologic and bacteriological researches
4 . Analysis of results of cytologic and bacteriological research, clinical analysis of blood.
5 . Medical record registration, scheduling of inspection and treatment of the patient by TB;
6 . Writing out the direction to the TB dispensary;
7 . Carrying out application anesthesia.
8 . Conducting irrigation, applications of drugs.
8. Terminology (in Latin script).
Tuberculosis (tuberculosis), tuberculosis Lupus (lupus vulgaris), ulcerative miliary tuberculosis
(tuberculosis miliaris ulcerosa), kolicvative tuberculosis (skrofuloderme) (tuberculous scrofuloderma).
9. Questions for the control of students' knowledge.
1. Etiology and pathogenesis of tuberculosis. Clinical forms.
2. Manifestations in the oral cavity of lupus, ulcerative-miliary tuberculosis, kollikvativnogo
tuberculosis.
3. Diagnosis of tuberculosis.
4. Differential diagnosis of tuberculosis.
5. Treatment, prevention. The tactics of dentist.
10. Tasks "CROK 2".
1. Which cells are characteristic for tuberculosis in the microscopic study of pathological tissues?
A. Giant cells of Pirogov-Langhans.
B. Foam cells.
C. Large onkoside cells.
D. Mast cells.
E. Stellate epithelial cells
2. A patient 37 years old went to the doctor with complaints of a painful ulcers on mucous
membrane of the mouth that makes him difficult to eat. Objectively: the mucous membrane of the
soft palate is painful ulcer with saped soft edges measuring 0.5 cm in diameter. Bottom is covered
with gray and yellow tubercles. Cytological study: the presence of Langhans cells. What is the
most likely diagnosis?
A. Setton's aphtha.
B. Tuberculous ulcer.
C. Syphilis.

D. Trophic ulcer.
E. Decubital ulcer.
3. A patient 47 years old complains on tulcers on the back side of the tongue. From the anamnesis
is know that before ulcer was papulose infiltrate during a long time. Which progressively
increased, and then formed an ulcer. Objectively: on the back side of the tongue is shallow oblong
ulcers, painful, surrounded by tubercles, with saped edges. What is the most likely diagnosis?
A. Primary syphilis.
B. Dekubital ulcer.
C. Actinomycosis language.
D. Tuberculous ulcer.
E. Abscess language.
4. A 34 years old patient addressed to the dentist with complains on ulcer on the hard palate, which
appeared about a one month ago. He was treated by rinses of herbs decoction, but the ulcer
gradually "creep." Objectively: the mucous membrane of the hard palate is shallow painful ulcer
with saped jagged edges, soft consistency, the bottom contains granulation. On the periphery of
the ulcer visible yellowish grain. What is the most likely diagnosis?
A. actinomycosis
B. Primary syphilophyma
C. trophic ulcer
D. tuberculous ulcer
E. A cancerous ulcer
5. A patient 33 years old complained on oral cavity ulcer on the bottom, which is located under the
tongue at the level of 43 to 33. On examination an ulcer has saped scalloped edge with not deep
bottom, gray-yellow in color, covered with fine granulation, easy bleeding. Infiltration ulcers
missing. Identify the clinical diagnosis.
A. Tuberculous ulcer on oral cavity bottom
B. Dekubital ulcer on oral cavity bottom
C. Gummy ulcer on oral cavity bottom
D. Migrating granuloma on oral cavity bottom
E. A cancerous ulcer on oral cavity bottom.
6. A patient 39 years old complains on the presence of ulcer and tubercles with the soft consistency
on the oral mucous membrane, bleeding gums, tooth mobility and pain. Objectively: the mucous
membrane of tongue, gums have solitary ulcers with soft edges slightly pain, swollen, covered
with yellow plaque. The regional lymph nodes are enlarged, soft, painless, not welded to the
surrounding tissues. What is the preliminary diagnosis?
A. Setton's aphtha
B. Syphilis (tertiary)
C. skrofuloderme
D. tuberculosis Lupus
E. Leprosy
7. To the dentist come 40 years old patient with complains on painful ulcer in the mouth. On
examination in the oral cavity on the mucous membrane of the hard palate sharply painful ulcer
size 1,5 x2 cm, covered with a yellowish coating, with soft edges and rim saped inflammation of
a pale red color. The bottom of the ulcer is uneven, gray. What are the preliminary diagnosis:
A. syphilitic ulcer
B. tuberculous ulcer
C. actinomycosis
D. Cancer of the mucous membrane of the sky
E. Necrotizing ulcerative stomatitis
8. The primary element in tuberculosis Lupus of the oral mucous membrane is:
A. wheal
B. Vesicle (hemorrhagic)
C. bubble
D. Tubercle (lyupoma)
E. Spot (telangiectasia)
9. Giant cells of Pirogov-Langhans found in cytologic preparation at:
A. pemphigus

B. Exudative erythema multiforme


C. Milliarno-ulcerative tuberculosis
D. Lichen ruber planus
E. Chronic recurrent aphthous stomatitis