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REVIEW ARTICLE

Oral manifestations of tuberculosis

Shekhar Kapoor, Sumir Gandhi1, Nitasha Gandhi2, Inderjot Singh1
Departments of Oral Medicine and Radiology, 1Oral and Maxillofacial Surgery, 2Prosthetic Dentistry,
Christian Dental College and Hospital, Ludhiana, Punjab, India

A B S T R A C T
Tuberculosis (TB) is still among the most life-threatening infectious diseases, resulting in high mortality in adults. A significant proportion of
patients (15-25%) exist in whom the active TB infection is manifested in an extrapulmonary site. Healthcare workers, including dentists, are
at the frontline and can make an important contribution to the control of this infectious epidemic. Oral TB has been considered to account
for 0.1-5% of all TB infections. Nowadays, oral manifestations of TB are re-appearing alongside many forgotten extrapulmonary infections
as a consequence of the outbreak and emergence of drug-resistant TB and of the emergence of acquired immune-deficiency syndrome.

Keywords: Drug-resistant, extrapulmonary, tuberculosis

INTRODUCTION proportion of patients (15-25%) exist in whom the active

World Health Organization (WHO) estimates that
the largest number of new tuberculosis (TB) cases in
2008 occurred in the South-east Asia region, which
accounted for 34% of incident cases globally.[1] However,
the estimated incidence rate in sub-Saharan Africa is
nearly twice that of the South-east Asia region with
over 350 cases per 100,000 population. Incidence of TB is
increasing in developing as well as developed countries
because of migrant population.[2] Increasing incidence
of HIV infection, lack of public health efforts to control
TB after its elimination, poverty, and emergence of
multidrug-resistant (MDR) TB are the reasons of increase
in TB incidence in developed countries.
TB is still among the most life-threatening infectious
diseases, resulting in high mortality in adults. With
an incidence of 139 per 100,000 (in 2007) active
Mycobacterium TB infections globally, it is estimated that
two billion people (i.e. one-third of the world’s population)
have been in contact with the TB bacillus. A significant
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DOI:
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TB infection is manifested in an extrapulmonary site.
Moreover, the emergence of drug-resistant TB has recently
raised serious concerns. TB is a frequent cause of missed
or complicated diagnosis in general medical settings.[1,2]
Healthcare workers, including dentists, are at the
frontline and can make an important contribution to
the control of this infectious epidemic. Oral TB has been
considered to account for 0.1-5% of all TB infections.[3]
Nowadays, oral manifestations of TB are reappearing
alongside many forgotten extrapulmonary infections
as a consequence of the outbreak and emergence of
drug-resistant TB and of the emergence of acquired
immunodeficiency syndrome (AIDS), where oral
TB is found to account for up to 1.33% of human
immunodeficiency virus (HIV)-associated opportunistic
infections, based on a cohort of 1,345 patients.[2,3] This
review, therefore, seeks to assess the manifestations and
symptoms of TB in the oral cavity as documented in
the literature published in English to the present date.
It is true that the dental identification of M. TB has the
potential of serving as an important aid in the first line
of control for this dangerous, and often fatal, disease.
Oral manifesta on
TB oral lesions are a relatively rare occurrence. Studies
vary, but the incidence has usually been reported as
less than 1% of the TB population. Saliva is believed
to have a protective effect, which may explain the

Corresponding Author: Dr. Shekhar Kapoor, Department of Oral Medicine and Radiology, Christian Dental College and Hospital,
Ludhiana - 141 008, Punjab, India. E-mail: shekhardr2000@yahoo.co.in

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Kapoor, et al.: Oral tuberculosis
paucity of TB oral lesions, despite the large numbers
of bacilli contacting the oral cavity mucosa in a typical
case of pulmonary tuberculosis. Other factors that
attribute to relative resistance of oral cavity for TB are
presence of saprophytes, resistance of striated muscles
to bacterial invasion, and thickness of protective
epithelial covering. It is believed that the organisms
enter the mucosa through a small break in the surface.
Local factor that may facilitate the invasion of oral
mucosa includes poor oral hygiene, leukoplakia, local
trauma, and irritation by clove chewing, and so on.
Self-inoculation by the patient usually results from
infected sputum or by hematogenous or lymphatic
dissemination.[3-5]
Oral TB lesions may be either primary or secondary in
occurrence. Primary lesions are uncommon, seen in
younger patients, and present as single painless ulcer
with regional lymph node enlargement. The secondary
lesions are common, often associated with pulmonary
disease, usually present as single, indurated, irregular,
painful ulcer covered by inflammatory exudates in
patients of any age group but relatively more common
in middle-aged and elderly patients.[2,3,6]
Oral TB may occur at any location on the oral mucous
membrane, but the tongue is most commonly affected.
Other sites include the palate, lips, buccal mucosa,
gingiva, palatine tonsil, and floor of the mouth. Salivary
glands, tonsils, and uvula are also frequently involved.
The retromolar region is rarely involved. Secondary
lesions of the mandibular ridge (alveolar mucosa)
are extremely rare. Primary oral TB can present with
painless ulceration of long duration and enlargement
of the regional lymph nodes.[3,6,7]
The oral lesions may present in a variety of forms,
such as ulcers, nodules, tuberculomas, and periapical
granulomas.[3,7,8] The identification of a TB lesion
in any location in the mouth is an unusual finding
and its discovery is usually indicative of underlying
pulmonary disease. Therefore, in all cases of oral cavity
TB, search for primary site of the disease should always
be considered even in the absence of any signs and
symptoms. The oral manifestations of TB can also be
in the form of superficial ulcers, patches, indurated
soft tissue lesions, or even lesions within the jaw that
may be in the form of TB osteomyelitis or simple bony
radiolucency.[8,9] Of all these oral lesions, the ulcerative
form is the most common.[3,6,10] It is often painful,
with no caseation of the dependant lymph nodes.
Oral lesions of TB are nonspecific in their clinical
12 CHRISMED Journal of Health and Research /Vol 1/Issue 1/Jan-Apr 2014
presentation and often are not considered in differential
diagnosis, especially when oral lesions are present
before systemic symptoms become apparent. Primary
gingival involvement is more common in children and
adolescents than adults.[3,7,11] It usually presents as a
single painless indolent ulcer, which 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 induration and satellite lesions are commonly
found.[4,9,12]
When oral TB occurs as a primary lesion, an ulcer is the
most common manifestation usually developing along
the lateral margins of the tongue which rest against
rough, sharp, or broken teeth or at the site of other
irritants. Patients with oral tubercular lesions often have
a history of preexisting trauma. Any area of chronic
irritation or inflammation may favor localization of
the Mycobacterium associated with the disease.[13,14]
Deep tubercular ulcers of the tongue are typical in
appearance with a thick mucous 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, dorsum, the midline, and base of the
tongue. They are irregular, pale, and indolent with
inverted margins and granulations on the floor with
sloughing tissue.[3,14,15]
Oral cavity TB is difficult to differentiate from other
conditions on the basis of clinical signs and symptoms
alone. While evaluating a chronic, indurated ulcer,
clinicians should consider both infectious process
such as primary syphilis and deep fungal diseases
and noninfectious processes such as chronic
traumatic ulcer and squamous cell carcinoma in the
list of differential diagnosis. If there is no systemic
involvement, one should go for excisional biopsy for
tissue diagnosis and bacteriologic examination with
culture for a definitive diagnosis. The efficiency
of demonstration of acid fast bacilli in histological
specimens is low, as there is relative scarcity of
tubercle bacilli in oral biopsies.[3,15]
According to various studies only a small percentage
(7.8%) of histopathology specimens stain positive for
acid fast bacilli.[11,16] Therefore, a negative result does
not rule out completely the possibility of TB. Another
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Kapoor, et al.: Oral tuberculosis

concern is the occurrence of mycobacterial infection as

a part of AIDS. Histologically, an immunocompromised
patient may not show granuloma or caseation. This poses
a potential problem in diagnosing TB. HIV-1-associated
TB is reaching epidemic proportions in many African
countries. The prevalence and incidence of TB is similar
in both HIV-positive and HIV-negative individuals, but
the risk of active TB was elevated only for seropositive
subjects. Increasing problems with TB may well
continue because of the continuing emergence of MDR
strains of M. TB, which is a major threat, particularly
with HIV- and AIDS-infected patients, among whom,
mortality rates are high.[8,11,17]

With the increasing number of TB cases, unusual Figure 1: Tuberculous ulcer on tongue

forms of the disease in the oral cavity are more

likely to occur and be misdiagnosed. Although rare,
doctors and dentists should be aware of the oral
lesions of TB and consider them in the differential
diagnosis of suspicious oral ulcers [Figure 1-3]. TB
of the oral cavity frequently simulates cancerous
lesions and others like traumatic ulcers, aphthous
ulcers, actinomycosis, syphilitic ulcer, or Wegener’s
granuloma. The traumatic ulcer, which occurs in
areas of chronic irritation from either sharp cusps or
prosthesis, is acute in presentation and exquisitely
tender. Also, the source of irritation is usually evident
Figure 2: Ulcer in buccal vestibule
on examination. The chronic indurated ulcer has to
be carefully distinguished from a carcinoma, as with
other TB lesions of head and neck, they can resemble
each other and frequently coexist.[3,4,15,18,19]

The history reported by the patient and the clinical

and radiological examination play an important part in
the diagnosis of TB. However, laboratory confirmation
is most essential for the diagnosis, with culture of
microorganisms taken as the absolute proof of the
disease. A biopsy of an oral lesion is confirmatory
but in majority of the cases, a single biopsy may not
suffice because the granulomatous changes may not
be evident in early lesions. The lesion is eventually
disclosed by repeat biopsies. The differential diagnosis Figure 3: Gingival enlargement
is made with the identification of a caseating granuloma
with associated epitheloid cells and giant cells of the such as isoniazide, rifampicin, pyrazinamide, and
Langerhans type during histological evaluation of ethambutol for 6 months.[3,19,20]
biopsied tissue. Deeper biopsies are always advocated
for ulcers of the tongue; a superficial biopsy may TB and den st
not reveal the etiology due to epithelial hyperplasia. TB is a recognized occupational risk for dentists, as we
A chest x-ray and a Mantoux skin test are mandatory work in close proximity to the nasal and oral cavities of
to rule out systemic TB. Most often complete remission patients, with generation of potentially infectious sprays
of tubercular ulceration of the tongue takes place after during routine operative procedures. A history of TB
standard antitubercular chemotherapy using antibiotics should prompt the clinician to distinguish whether the

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Kapoor, et al.: Oral tuberculosis
person is an active case under treatment, active case
without treatment or previously infected but currently
disease free. The nontreated active cases pose maximum
risk to the dental personnel.
Only dental emergencies should be undertaken for
treatment under controlled environment for active cases
of TB, such as the one described here. The constant
risk of contracting the disease should encourage the
dental clinicians to follow basic precautions of using
face masks, protective eye gear, and gloves. Also, high
standards of operatory disinfection and instrument
sterilization should be maintained.[7,20-22]
CONCLUSION
Though rare, TB should be included in the differential
diagnosis of chronic ulcers of the tongue. The dentist
should realize the importance of his role in detection of
TB in patients who have asymptomatic oral lesions and
are unaware of the disease. However, the mere diagnosis
of such lesions is not sufficient and a persistent follow-up
is of equal, if not more, importance. Identification of TB
is of significance not only to the patient himself, but
also to the dental team that comes in contact and the
community at large, where the patient can be a potential
source for spread of infection.
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Cite this article as: Kapoor S, Gandhi S, Gandhi N, Singh I. Oral manifestations
of tuberculosis. CHRISMED J Health Res 2014;1:11-4.
Source of Support: Nil. Conflict of Interest: No.