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Case Report
Primary tuberculosis of the oral cavity
Kamala R, Abhishek Sinha, Amitabh Srivastava1, Sunita Srivastava

Departments of Oral Medicine

and Radiology, 1Periodontics
and Implantology, Sardar Patel
Post Graduate Institute of
Dental and Medical Sciences,
Lucknow, Uttar Pradesh, India

Received
: 19-02-10
Review completed : 14-09-10
Accepted
: 29-04-11

ABSTRACT
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.
Key words: Epitheloid cells, oral tuberculosis, oral ulcers, tuberculosis

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 cows
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]
Address for correspondence:
Dr. Sunita Srivastava
E-mail: srivas914@yahoo.com
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DOI:
10.4103/0970-9290.94680

835

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 patients 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].
Indian Journal of Dental Research, 22(6), 2011

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Primary tuberculosis of the oral cavity

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].
The other mucosal surface involved was the palatal mucosa
with single oval ulcer, measuring 1 1cm, present in the
anterior mid palate with undermined margins. The surface
of ulcer was granular [Figure 3].
Correlating the patients 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 [Figure4].
Laboratory investigation which included routine hematologic
examination showed a raised erythrocyte sedimentation
rate (ESR) (55mm/1st hr Wintrobe). Analysis for Human
Immunodeficiency Virus (HIV) and Venereal Disease
Research Laboratory were negative. Mantoux test was
positive 12mm 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 [Figures 5 and 6].
Correlating the patients 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 600mg/day, isoniazid
300mg/day, and pyrazinamide 1500mg/day, ethambutol
1200mg/day for two months followed by isoniazid 300mg/
day and rifampicin 600mg/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
Indian Journal of Dental Research, 22(6), 2011

Kamala, etal.

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]
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Kamala, etal.

Primary tuberculosis of the oral cavity

Figure 1: Intraoral photograph showing ulcer in right maxillary gingiva

Figure 2: Photograph showing ulcerated gingiva

Figure 3: Intraoral photograph showing palatal ulceration

Figure 4: Chest radiograph showing no abnormality

Figure 5: Photomicrograph showing multinucleated giant cells

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
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Figure 6: Photomicrograph showing acid fast bacilli

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
Indian Journal of Dental Research, 22(6), 2011

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Kamala, etal.

Primary tuberculosis of the oral cavity

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.

ACKNOWLEDGEMENT
We would like to thank Department of Oral and Maxillofacial
pathology for their contribution for preparing the slide.

Indian Journal of Dental Research, 22(6), 2011

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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.
Source of Support: Nil, Conflict of Interest: None declared.

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