Vol. 125 No.

1 January 2018

Clinical and pathologic analyses of tuberculosis in the oral

cavity: report of 11 cases
Wu-tong Ju, MD,a Yong Fu, MD,a Ying Liu, MD,a Yi-ran Tan, MD,a Min-jun Dong, MD,b Li-zhen Wang, MD,c
Jiang Li, MD,c and Lai-ping Zhong, MD, PhDa

Objective. The aim of this study was to analyze tuberculosis (TB) in the oral cavity according to clinical appearance, clinical
differential diagnosis, treatment, and outcome.
Study Design. We enrolled 11 patients with TB in the oral cavity between November 2012 and November 2016. Glossal lym-
phoid TB was excluded. Clinical symptoms, auxiliary examinations, treatments, and outcomes were recorded and analyzed.
Results. The study population comprised 6 men and 5 women, with a mean age of 59 years. Five patients presented with ulcer,
5 with a mass, and 1 with osteomyelitis. Excisional biopsy was performed in 3 patients, mass resection in 7, and curettage of
mandibular lesion in 1. After pathologic diagnosis of TB in the oral cavity in 8 patients; 6 of them underwent purified protein
derivative examination, and 4 of them had positive results and received drug therapy. The mean follow-up period was 24.9 months,
and there was no recurrence.
Conclusions. TB in the oral cavity is rare and has no specific clinical features. Pathology, acid-fast staining, polymerase chain
reaction, and DNA testing for Mycobacterium tuberculosis are useful for final diagnosis. Surgery is recommended as the treat-
ment of choice to achieve good clinical outcomes. (Oral Surg Oral Med Oral Pathol Oral Radiol 2018;125:44–51)

Tuberculosis (TB) is a chronic disease caused by My-
cobacterium tuberculosis infection, with high morbidity
rates reported in Southeast Asia and Africa.1 The lung
is the predominant site of TB. Primary pulmonary TB
should be distinguished from postprimary pulmonary TB,
which is the most frequent manifestation of TB in adults
(70%–80% of cases).2 The host inflammatory reactions
play an important role in protection from this disease as
well as its pathology.3 In the initial stage of M. tuber-
culosis infection, additional macrophages and other
immune cells aggregate with the infected cells to form
granulomas, the morphology of which is characterized
by a central necrotic core surrounded by concentric layers
of macrophages, epithelioid cells, multinucleate Langer-
hans giant cells, and lymphocytes.4 A balance between
pathogen replication and the immune response is estab-
lished, and the lesions move into a latent state in most
patients. Only in certain situations, such as immune dys-
function, does primary TB occur. Secondary TB involves
the reactivation of the dormant bacteria and accounts for
most cases of TB. TB-infected tissues can be damaged
The informed consent form was approved by the institutional review
board of Ninth People’s Hospital, Shanghai Jiao Tong University School
of Medicine.
This study was supported by research grants (No. 81672660 and No.
81472519) from the National Natural Science Foundation of China.
a
Department of Oral and Maxillofacial–Head and Neck Oncology, Ninth
People’s Hospital, Shanghai Jiao Tong University School of Medicine,
Shanghai, China.
b
Department of Radiology, Ninth People’s Hospital, Shanghai Jiao Tong
University School of Medicine, Shanghai, China.
c
Department of Oral Pathology, Ninth People’s Hospital, Shanghai Jiao
Tong University School of Medicine, Shanghai, China.
Received for publication May 5, 2017; returned for revision Sep 14,
2017; accepted for publication Sep 21, 2017.
© 2017 Elsevier Inc. All rights reserved.
2212-4403/$ - see front matter
https://doi.org/10.1016/j.oooo.2017.09.015
through a variety of mechanisms, including low oxygen
tension and a restricted nutrient supply.5,6 If patients with
TB are not diagnosed and treated appropriately and in
a timely manner, the disease can cause serious damage
to the body and even death.7,8
Extrapulmonary TB affects any site other than the
lungs, although it is sometimes accompanied by pulmo-
nary disease. The lymph nodes are the most common
location of TB after the lungs.9,10
TB lesions in the oral cavity are rare,11 and most orig-
inate from pulmonary TB, so they can be considered
secondary TB. Primary TB in the oral cavity without pul-
monary involvement is rare, but it is more commonly
found in children and adolescents.12,13 Secondary TB in
the oral cavity accounts for the vast majority of cases of
TB at this site, but the incidence is low. Therefore, primary
clinical diagnosis of TB in the oral cavity is always dif-
ficult. Because of the rarity of TB in the oral cavity, no
protocol has been established for the treatment of this
condition.12
Twenty-three cases of TB in the oral cavity have been
reported so far in the literature.14-24 Among them, the most
common sites of lesion included the gingiva, buccal
mucosa, and palate. All the cases were definitively di-
agnosed through incisional biopsy and pathologic
examination. Many auxiliary examinations yielded
Statement of Clinical Relevance
Tuberculosis in the oral cavity is rare and has no spe-
cific clinical features. Pathology and other auxiliary
examinations are necessary for diagnosis. Surgery is
recommended as the main treatment for good clini-
cal outcomes.

44
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Volume 125, Number 1
variable positive results, which made clinical differen-
tial diagnosis difficult. All the patients received drug
therapy, and most of them had a good clinical outcome,
with the exception of 1 patient, who had a recurrence of
the pulmonary lesion because his drug therapy was not
completed14-24 (Supplementary Table I).
In the present study, we analyzed 11 patients who had
TB in the oral cavity and were treated in our depart-
ment in 2012-2016. We reviewed and analyzed their
clinical and pathologic data, treatments, and outcomes,
focusing on clinical appearances and differential
diagnoses.
PATIENTS AND METHODS
We enrolled 11 patients with TB in the oral cavity between
November 2012 and November 2016, excluding those
with a medical history of TB. Patients with lesions in-
volving the glossal lymph nodes, salivary glands,
oropharynx, tonsils, or sinuses were also excluded, so
were patients with human immunodeficiency virus (HIV)
infection or diabetes or who had previously received che-
motherapy. All the patients were treated in the Department
of Oral and Maxillofacial–Head and Neck Oncology,
Ninth People’s Hospital, Shanghai Jiao Tong Universi-
ty School of Medicine, Shanghai, China. The study was
approved by our hospital Ethics Committee. The pa-
tients’ general conditions, clinical signs and symptoms,
imaging results, pathologic results, treatment methods,
and clinical outcomes were reviewed and analyzed
(Table I). After giving signed informed consent, all the
patients underwent surgical intervention. The patholog-
ic diagnosis was confirmed by 2 experienced oral
pathologists. All patients were followed-up on return visits,
during which a routine physical examination was per-
formed. If there was any suspicious mass in the oral cavity
region or if otherwise necessary, an imaging examina-
tion and/or biopsy were suggested. The index of success
was defined as the absence of any suspicious mass in the
oral cavity.
RESULTS
General condition
Of the 11 patients included in the study, 6 were men and
5 were women, aged 48 to 78 years (mean age 59.1 years).
Location of lesion
Five patients had lesions in the gingiva, 4 patients had
lesions in the buccal mucosa, 1 patient had a lesion on
the lip, and 1 patient had a lesion in the mandible.
Symptoms
Five patients presented with a single unhealed ulcer in
the oral cavity (4 lesions in the gingiva and 1 in the buccal
mucosa); 5 patients presented with a mass in the oral
cavity (3 lesions in the buccal mucosa, 1 in the gingiva,
ORIGINAL ARTICLE
Ju et al. 45
and 1 on the lip); and 1 patient presented with repeated
swelling and pain in the left mandibular region. None
of the 11 patients complained of TB infection or had a
history of TB vaccination; no specific systematic dis-
eases or symptoms were present.
Physical examination
In the 5 patients with ulcers, the sizes of the ulcers ranged
from 1 × 1 cm2 to 2 × 2 cm2; and 3 ulcers were accom-
panied by bone absorption, which had been clinically
misdiagnosed as squamous cell carcinoma. In the 5 pa-
tients with masses, the size of the masses ranged from
1 × 1 cm2 to 2 × 2 cm2, and they occurred as small nodules
with clear borders. In the patient with repeated swell-
ing and pain in the left mandibular region, no abnormal
signs were found in the oral cavity, apart from an ab-
normal imaging finding, which had previously been
diagnosed as osteomyelitis. Only 1 of the 11 patients had
an enlarged cervical lymph node, which was <3 cm in
diameter.
Imaging
Computed tomography (CT) scans were performed in 7
patients, but no obvious consistent findings were de-
tected. Some masses had clear borders, whereas some
had unclear borders; some masses showed bone infil-
tration, whereas some did not (Figures 1 to 3). Panoramic
radiography of the patient previously diagnosed with os-
teomyelitis showed a low-density area with an unclear
border in the left mandibular ramus (Figure 4). Chest ra-
diography was performed in 7 of the 11 patients, and 5
were considered to show sequelae of pulmonary TB
(Figure 5). Therefore, 2 patients were considered to have
primary TB in the oral cavity, and the 5 patients who pre-
sented with sequelae of pulmonary TB were considered
to have secondary TB in the oral cavity.
Laboratory examination
No obvious abnormalities were found in routine labo-
ratory examinations, including negative results for serum
HIV in all 11 patients. None of the 11 patients dis-
played lowered resistance or increased virulence of the
organism.
Treatment
An excisional biopsy was performed, with the patient
under local anesthesia, in 3 of the 11 patients; the mass
was resected, with the patient under general anesthesia,
in 7 patients; and in the remaining patient, who had pre-
viously been diagnosed with osteomyelitis, the lesion was
curetted, with the patient under general anesthesia.
After 6 patients were diagnosed with TB in the oral
cavity, through pathologic examination, they under-
went a Mantoux test (purified protein derivative test
 46 Ju et al.
ORAL AND MAXILLOFACIAL PATHOLOGY
Table I. Summary of clinical and follow-up information in the 11 patients with TB in the oral cavity
Cervical Duration of
Age Size Chest Acid-fast lymph follow-up
No. Gender (y) Location and symptoms (cm × cm) radiograph* PPD staining node† (months) Treatment Clinical outcomes
1 Female 53 Gingival mass 1×1 None None + N0 48 Resection Ten patients were followed up. No
2 Male 76 Buccal mass 2×2 + None ‡
N0 Lost Resection recurrence of oral lesion was
3 Male 61 Gingival ulcer 1.5 × 1.5 + + + N0 38 Incisional biopsy and drug therapy found. Four patients with positive
4 Male 78 Gingival ulcer 1.5 × 2 + None + N0 36 Resection PPD had no other TB-related
5 Male 60 Buccal mass 1.5 × 1.5 ‡
+ ‡
N1 35 Resection and drug therapy symptoms. Enlarged cervical
6 Male 59 Gingival ulcer 2×2 + + + N0 27 Incisional biopsy and drug therapy lymph node shrank in Patient #5.
7 Male 49 Gingival ulcer 2×2 + + + N0 19 Resection and drug therapy
‡
8 Female 68 Swelling and pain in the None None N0 16 Curettage
mandibular area
9 Female 50 Buccal mass 1.5 × 1.5 ‡ ‡
+ N0 14 Resection
10 Female 48 Lip mass 2×2 None ‡
+ N0 8 Incisional biopsy and observation
11 Female 48 Buccal ulcer 1×1 None none + N0 8 Resection
PPD, purified protein derivative; TB, tuberculosis.
*Chest radiograph “+”: Intrapulmonary calcification patch, suggesting old pulmonary tuberculosis.
†
Cervical lymph node “N0”: No lymph node enlargement. “N1”: Single lymph node enlargement with the diameter of the node not larger than 3 cm.
‡
Normal.

January 2018
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Volume 125, Number 1
Fig. 1. Computed tomography (CT) scan of the maxillofacial
region of patient 9 showing a mass with a sharp border in the
right buccal area.
Fig. 2. Computed tomography (CT) scan of the maxillofacial
region of patient 7 showing a lesion with infiltration in the gin-
gival area of the right maxilla.
ORIGINAL ARTICLE
Ju et al. 47
Fig. 3. Computed tomography (CT) scan of the maxillofacial
region of patient 6 showing a mass with bone infiltration in the
left lingual side of the mandible.
Fig. 4. Panoramic radiograph of patient No. 8 showing a low-
density area with an unclear border in the left mandibular ramus.
[PPD]) in a specialist infectious disease hospital, and pos-
itive results were reported for 4 patients. These patients
received further anti-TB drug therapy in the specialist
infectious disease hospital.
Pathologic examination
All the histologic slides from the 11 patients showed
granulomas consisting of epithelioid histiocytes and mul-
tinucleate Langerhans giant cells. Central necrotic foci
were detected in 5 patients (Figure 6). Paraffin-embedded
tissues from all 11 patients were tested with acid-fast stain,
ORAL AND MAXILLOFACIAL PATHOLOGY OOOO
48 Ju et al. January 2018

and carbol-fuchsin-stained M. tuberculosis was de- Clinical outcomes

tected in 8 of them (Figure 7). The 3 patients with negative
results had typical histologic manifestations but were still
diagnosed with TB. All pathologic diagnoses were con-
firmed by 2 experienced oral pathologists.
Only 1 patient was lost to follow-up. The other 10 pa-
tients were followed up for 8 to 48 months (average 24.9
months). No recurrence was found at either an oral site
or a pulmonary site. One patient died of lung cancer, but
the others remained alive and well.

Fig. 5. Chest radiograph of patient 8 showing a patch of in-
trapulmonary calcification, suggesting old pulmonary
tuberculosis.
DISCUSSION
TB in the oral cavity is an uncommon disease com-
pared with TB in the lung or cervical lymph nodes. The
clinical outcomes are good for patients who had TB in
the oral cavity and had received surgical treatment at our
hospital. Therefore, we analyzed TB in the oral cavity,
highlighting the effectiveness of surgical treatment. In
this study, we excluded patients with TB of the glossal
lymphoid because lymphoid tissue is abundant at the base
of the tongue. Several mechanisms potentially make the
oral cavity resistant to M. tuberculosis, including the intact
oral mucosa, which provides a local barrier; various
enzymes and antibodies in the saliva; the salivary flush-
ing effect; and the oral microbial environment.25 Therefore,
clinicians and surgeons must apply increased vigilance
in the detection of TB in the oral cavity, particularly when
patients display TB-related symptoms, such as fever, night
sweats, or cough.
Unfortunately, TB in the oral cavity has no charac-
teristic signs or symptoms. Among the 11 patients enrolled
in this study, no one had a previous medical history of

Fig. 6. Histologic photograph of a tissue sample from Patient 7 (hematoxylin and eosin staining; original magnification, A, ×40,
B, ×200) showing a granulomatous lesion consisting of epithelioid histiocytes and multinucleated Langerhans giant cells, with a
central necrotic focus surrounded by lymphocytes.

Fig. 7. Photographs of paraffin-embedded tissue samples from patients 1 (A) and 11 (B) (acid-fast staining; original magnifica-
tion, ×1000) showing carbol-fuchsin–stained Mycobacterium tuberculosis.
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Volume 125, Number 1
TB; only 1 patient had a medical history of squamous
cell carcinoma in the oral cavity. In terms of symp-
toms, ulcers and masses were the major complaints.
Imaging and laboratory examination provided no char-
acteristic information for differential diagnosis. Clinically,
the differential diagnosis of tuberculous ulcers in the oral
cavity should include squamous cell carcinoma, trau-
matic ulcer, syphilitic ulcer, actinomycosis, and Wegener
granulomatosis,26 and the differential diagnosis of tu-
berculous masses should include tumors and cysts. It is
sometimes difficult to make a differential diagnosis only
on the basis of imaging because there are no character-
istic imaging findings of TB in the oral cavity. Therefore,
without pathologic examination, it is always difficult for
clinicians or surgeons to diagnose TB in the oral cavity
correctly. In the present study, primary clinical misdi-
agnoses, including those of squamous cell carcinoma,
traumatic ulcers, and fibroma, had been made in our 11
patients. This reminds us that feasible auxiliary exami-
nations, including pathologic examination, acid-fast
staining, PPD, and chest radiography, are necessary.
Sputum smear microscopy, solid culture, chest radi-
ography, and PPD are traditionally considered useful in
the diagnosis of TB.27,28 However, these tests are time con-
suming and also lack sufficient sensitivity and specificity.
In recent years, several diagnostic detection methods based
on TB-related molecules in blood or saliva specimens have
been reported to be more accurate, with easier, safer, and
more uniform sample collection.29,30 However, as these
methods are complex, their implementation in the health
care system can be difficult.
If possible, a pathologic biopsy of the oral lesion
should be performed as early as possible. The charac-
teristic histologic manifestations of TB include a
granuloma, consisting of epithelioid histiocytes and mul-
tinucleate Langerhans giant cells, with a central necrotic
focus that is usually acidophilic and surrounded by
lymphocytes. Some TB granulomas can also be of the
hyperplastic type, with a proliferation of fibrous tissue
and with no necrotic center.31 Histologic diagnosis is a
reliable method, but there is an error rate. Acid-fast
staining is necessary. In the present study, paraffin-
embedded tissue from all 11 patients were subjected to
acid-fast staining, and carbol-fuchsin-stained M. tuber-
culosis was detected in 8 of them, giving a positivity
rate of 72.7%, consistent with a previous report.32 The
3 patients with negative results showed the typical his-
tologic manifestations of TB and were still diagnosed
with TB by oral pathologists. Thus, the combination of
a histologic diagnosis, acid-fast staining, and the detec-
tion of M. tuberculosis DNA would ensure an accurate
diagnosis.32-34
When patients are diagnosed with TB in the oral
cavity, personalized treatments should be planned on
the basis of clinical examination results. The most popular
ORIGINAL ARTICLE
Ju et al. 49
anti-TB drugs include isoniazid, rifampicin, pyrazin-
amide, ethambutol, and streptomycin. The combined
use of several kinds of these drugs is recommended.35
However, a course of anti-TB drugs usually lasts >6
months,36 and there can be adverse drug reactions, the
most common of which is upper abdominal pain.37 In
recent years, many studies on multidrug-resistant M.
tuberculosis have reported the challenges for anti-TB
drug therapies.38 Further research is required to develop
new treatment protocols.
According to chest radiography results, of 7 patients
in this study, 2 were considered to have primary TB in
the oral cavity, and 5 patients who presented with se-
quelae of pulmonary TB were considered to have
secondary TB in the oral cavity. On the basis of the find-
ings of this study, we suggest the following treatment
protocols for TB. Complete resection of the lesion is rec-
ommended for patients with primary resectable TB in the
oral cavity but no TB lesions at any other site in the body.
When patients are confirmed to have TB through patho-
logic examination, TB-related auxiliary examinations are
recommended to confirm TB activity in the body. If pos-
itive activity is confirmed, further anti-TB drug therapy
is necessary. Anti-TB drug therapy is recommended for
patients diagnosed simply through incisional biopsy. If
the lesions cannot be controlled, surgery is recom-
mended to remove the lesions from the oral cavity. On
the basis of a comparison between the follow-up results
in this study and those of the previous cases reviewed
(Supplementary Table I), we consider that the clinical
outcomes are good for all patients with TB in the oral
cavity. Therefore, we recommend that surgery be an op-
tional treatment for TB in the oral cavity, without denying
the importance of drug therapy.
For patients with maxillary or mandibular TB osteo-
myelitis, anti-TB drug monotherapy has been shown to
give a good prognosis, but the treatment takes about 6
months.39-41 In our study, mandibular TB osteomyelitis
was cured by surgical curettage alone, and the treat-
ment duration was short. Therefore, for the patients with
single mandibular or maxillary TB osteomyelitis, sur-
gical removal is recommended if the lesion can be
removed easily. Clinical outcomes for patients with TB
in the oral cavity have been consistently good.
There were several limitations to our study. The sample
size was relatively small, and we could not undertake drug
therapy at our hospital. Future multidisciplinary clini-
cal studies with larger samples should provide more
credible conclusions.
CONCLUSIONS
Tuberculosis in the oral cavity is rare, with no specific
clinical appearance. Pathology, acid-fast staining, poly-
merase chain reaction, or DNA test for Mycobacterium
tuberculosis is useful for diagnosis of tuberculosis in the
ORAL AND MAXILLOFACIAL PATHOLOGY
50 Ju et al.
oral cavity. Surgery is suggested as the treatment of choice,
with good clinical outcomes.
SUPPLEMENTARY DATA
Supplementary data related to this article can be found
at https://doi.org/10.1016/j.oooo.2017.09.015.
REFERENCES
1. World Health Organization. Global Tuberculosis Report 2014.
Geneva, Switzerland: WHO Press; 2014.
2. Loddenkemper R, Lipman M, Zumla A. Clinical aspects of adult
tuberculosis. Cold Spring Harbor Perspect Med. 2015;6:a017848.
3. Lyadova IV. Neutrophils in tuberculosis: heterogeneity shapes the
way? Mediators Inflamm. 2017;2017:8619307.
4. Volkman HE, Pozos TC, Zheng J, Davis JM, Rawls JF,
Ramakrishnan L. Tuberculous granuloma induction via interac-
tion of a bacterial secreted protein with host epithelium. Science.
2010;327:466-469.
5. Ulrichs T, Kaufmann SH. New insights into the function of granu-
lomas in human tuberculosis. J Pathol. 2006;208:261-269.
6. Belton M, Brilha S, Manavaki R, et al. Hypoxia and tissue de-
struction in pulmonary TB. Thorax. 2016;71:1145-1153.
7. Chung-Delgado K, Guillen-Bravo S, Revilla-Montag A, Bernabe-
Ortiz A. Mortality among MDR-TB cases: comparison with drug-
susceptible tuberculosis and associated factors. PLoS ONE. 2015;
10:e0119332.
8. Manjelievskaia J, Erck D, Piracha S, Schrager L. Drug-resistant
TB: deadly, costly and in need of a vaccine. Trans R Soc Trop Med
Hyg. 2016;110:186-191.
9. Popescu MR, Calin G, Strambu I, et al. Lymph node tuberculosis-
an attempt of clinico-morphological study and review of the
literature. Rom J Morphol Embryol. 2014;55:553-567.
10. Shivakoti R, Sharma D, Mamoon G, Pham K. Association of HIV
infection with extrapulmonary tuberculosis: a systematic review.
Infection. 2017;45:11-21.
11. Cleveland JL, Robinson VA, Panlilio AL. Tuberculosis epidemi-
ology, diagnosis and infection control recommendations for dental
settings: an update on the centers for disease control and preven-
tion guidelines. J Am Dent Assoc. 2009;140:1092-1099.
12. Robert G, David I. Head and neck manifestation of tuberculosis.
Oral Maxillofacial Surg Clin N Am. 2008;20:635-642.
13. Jain P, Jain I. Oral manifestations of tuberculosis: step towards
early diagnosis. J Clin Diagn Res. 2014;8:ZE18-ZE21.
14. Sezer B, Zeytinoglu M, Tuncay U, Unal T. Oral mucosal ulceration:
a manifestation of previously undiagnosed pulmonary tuberculo-
sis. J Am Dent Assoc. 2004;135:336-340.
15. Kilic A, Gul U, Gonul M, Soylu S, Cakmak SK, Demiriz M. Ori-
ficial tuberculosis of the lip: a case report and review of the literature.
Int J Dermatol. 2009;48:178-180.
16. Ebenezer J, Samuel R, Mathew GC, Koshy S, Chacko RK,
Jesudason MV. Primary oral tuberculosis: report of two cases.
Indian J Dent Res. 2006;17:41-44.
17. Tovaru S, Costache M, Sardella A. Primary oral tuberculosis: a
case series from Bucharest, Romania. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2008;105:e41-e45.
18. Wang WC, Chen JY, Chen YK, Lin LM. Tuberculosis of the head
and neck: a review of 20 cases. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2009;107:381-386.
19. Singhaniya SB, Barpande SR, Bhavthankar JD. Oral tuberculo-
sis in an asymptomatic pulmonary tuberculosis. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2011;111:e8-e10.
20. Jaiswal R, Singh A, Badni M, Singh P. Oral tuberculosis involv-
ing maxillary gingiva. Natl J Maxillofac Surg. 2011;2:175-176.
OOOO
January 2018
21. Peck MT, Stephen LX, Marnewick J, Majeed A. Palatal ulcer-
ation as the first sign of pulmonary tuberculosis: a case report. Trop
Doct. 2012;42:52-53.
22. Rosado P, Fuente E, Gallego L, Calvo N. Primary tuberculosis of
the palate. BMJ Case Rep. 2014;2014:pii: bcr2013203306.
23. Jan SM, Khan FY, Bhat MA, Behal R. Primary tuberculous gin-
gival enlargement—a rare clinical entity: case report and brief review
of the literature. J Indian Soc Periodontol. 2014;18:632-636.
24. Yashveer JK, Kirti YK. Presentations and challenges in tubercu-
losis of head and neck region. Indian J Otolaryngol Head Neck
Surg. 2016;68:270-274.
25. Popescu MR, Plesea IE, Olaru M, et al. Morphological aspects
in tuberculosis of oral cavity—our experience and a review of the
literature attempt. Rom J Morphol Embryol. 2015;56:967-987.
26. Santiago RA, Gueiros LA, Porter SR, et al. Prevalence of oral
lesions in Brazilian patients with tuberculosis. Indian J Dent Res.
2013;24:245-248.
27. Lawn SD, Mwaba P, Bates M, et al. Advances in tuberculosis
diagnostics: the Xpert MTB/RIF assay and future prospects for a
point-of-care test. Lancet Infec Dis. 2013;13:349-361.
28. Auld SC, Click ES, Heilig CM, et al. Tuberculin skin test result
and risk of death among persons with active TB. PLoS ONE. 2013;
8:e78779.
29. Wood RC, Luabeya AK, Weigel KM, et al. Detection of Myco-
bacterium tuberculosis DNA on the oral mucosa of tuberculosis
patients. Sci Rep. 2015;5:8668.
30. Palakuru SK, Lakshman VK, Bhat KG. Microbiological analysis
of oral samples for detection of mycobacterium tuberculosis by
nested polymerase chain reaction in tuberculosis patients with peri-
odontitis. Dent Res J (Isfahan). 2012;9:688-693.
31. Ehlers S, Schaible UE. The granuloma in tuberculosis: dynamics
of a host-pathogen collusion. Front Immunol. 2013;3:411.
32. Raslan WF, Rabaan A, Al-Tawfiq JA. The predictive value of Gen-
Probe’s amplified Mycobacterium tuberculosis direct test compared
with culturing in paraffin-embedded lymph node tissue exhibit-
ing granulomatous inflammation and negative acid fast stain. J Infect
Public Health. 2014;7:251-256.
33. Ryan GJ, Shapiro HM, Lenaerts AJ. Improving acid-fast
fluorescent staining for the detection of mycobacteria using a new
nucleic acid staining approach. Tuberculosis (Edinb). 2014;94:
511-518.
34. Han J, Zeng F, Zhou Y. The value of T-SPOT.TB in early diag-
nosis of tracheobronchial tuberculosis. Sarcoidosis Vasc Diffuse
Lung Dis. 2016;32:336-341.
35. Alsultan A, Peloquin CA. Therapeutic drug monitoring in the treat-
ment of tuberculosis: an update. Drugs. 2014;74:839-854.
36. Kee AR, Gonzalez-Lopez JJ, Al-Hity A, et al. Anti-tubercular
therapy for intraocular tuberculosis: a systematic review and meta-
analysis. Surv Ophthalmol. 2016;61:628-653.
37. Sadiq S, Khajuria V, Tandon VR, Mahajan A, Singh JB. Adverse
drug reaction profile in patients on anti-tubercular treatment alone
and in combination with highly active antiretroviral therapy. J Clin
Diagn Res. 2015;9:FC1-FC4.
38. Ahmad S, Mokaddas E. Current status and future trends in the di-
agnosis and treatment of drug-susceptible and multidrug-resistant
tuberculosis. J Infect Public Health. 2014;7:75-91.
39. Sheikh S, Pallagatti S, Gupta D, et al. Tuberculous osteomyelitis
of mandibular condyle: a diagnostic dilemma. Dentomaxillofac
Radiol. 2012;41:169-174.
40. Dinkar AD, Prabhudessai V. Primary tuberculous osteomyelitis
of the mandible: a case report. Dentomaxillofac Radiol. 2008;37:
415-420.
41. Kannaperuman J, Natarajarathinam G, Rao AV, Palanimuthu S.
Primary tuberculous osteomyelitis of the mandible: a rare case
report. Dent Res J (Isfahan). 2013;10:283-286.
OOOO ORIGINAL ARTICLE
Volume 125, Number 1 Ju et al. 51

Reprint requests: Li-zhen Wang, MD

Department of Oral and Maxillofacial-Head and Neck Oncology
Lai-ping Zhong, PhD
Department of Oral and Maxillofacial-Head and Neck Oncology Ninth People’s Hospital
Shanghai Jiao Tong University School of Medicine
Ninth People’s Hospital
Shanghai Jiao Tong University School of Medicine No. 639 Zhizaoju Road
Shanghai 200011
No. 639 Zhizaoju Road
Shanghai 200011 China
Wanglizhen9th@hotmail.com
China
Zhonglp@hotmail.com