Oral Diseases (I 996) 2, 242-243

0 1996 Srockron Press All rinhts reserved. 1354-523x196112.W

CASE REPORT

Oral tuberculosis

A Kolokotronis, D Antoniadis, G Trigonidis, P Papanagiotou

Depurttneiit of O r d Medicitie uiid P i i t l ~ o l o ~Scliool
~y, of Detitistiy. Arisrotle Uniwrsity of Tliesstrloniki. Greece

A case with oral tuberculosis and unaware of systemic
tuberculosis is reported. The oral lesions clinically mani-
fested as two painless ulcerations in the hard palate. Pul-
monary tuberculosis was diagnosed following the histopa-
thologic and bacteriologic examination of the oral
lesions.
Keywords: tuberculosis; oral tuberculosis; oral ulcers
Introduction
Tuberculosis has always been a major public health hazard.
With the advent of chemotherapy the incidence of tubercu-
losis declined markedly in certain parts of the Western
world. However it remains a major health problem in vari-
ous geographic locations (Dimitracopoulos et al, I99 I ).
Although the overall incidence of tuberculosis has
decreased, recently the incidence of this disease appears to
be increasing (Wood, 1992). This apparently is linked to
the incidence of AIDS in a population that is more suscep-
tible to tuberculosis (Barnes et al, 1991). In the USA, new
cases of this disease exceed 20000 per year (DoIan and
Yankell, 1992) and those with a latent infection are esti-
mated to range from 10-15 million (DoIan and Yankell,
1992).
Oral lesions seem to occur in 3-5% of all tuberculosis
cases (Dahlen et nl, 1992) and may occur in any oral tissue
or organ.
We describe a patient with tuberculosis of the hard pal-
ate, following pulmonary infection. We note that the patient
ignored the lung infection and the oral lesions led to the
diagnosis of tuberculosis.
remained unhealed after conservative therapy. Careful
questioning elicited that she had suffered no previous ill-
ness and had always been in good health.
Oral examiniition revealed two painless 0.5-cm circular
ulcerations on the hard palate (Figure 1). The ulcerations
showed irregular diameter and undermined borders. The
depth was granular and the base was hard. Palpation
showed no lymph node enlargement.
The radiographic study of the maxillofacial area did not
show any abnormality. Biopsy of the first lesion was taken.
Microscopic examination of the specimen showed a chronic
inflammation characterized by tuberculous granulomas con-
sisting of epithelioid cells and Langhan’s giant cells, sur-
rounded by lymphocytic infiltrations (Figure 2). These fea-
tures were consistent with a diagnosis of tuberculosis. Acid-
fast bacilli were not found in smears from specimens of the
second ulcer. However culture of a section of the tissue of
this second lesion was positive after incubation for 4 weeks,
and M. tcrberciilo.si.s developed. A Mantoux test was
strongly positive at a strength of 1:10000 and a chest X-
ray showed an old tuberculous focus in the right lung
(Figure 3).
A diagnosis of tuberculosis was made and the patient
was referred to the pulmonary medical section for further
investigation and treatment. Antituberculotic therapy was
administered for a I-year period and after 2 years the pati-
ent was healthy.

Report of case
A 70-year-old apparently healthy woman was referred to
the Oral Medicine and Pathology Department of Dentistry
School of the University of Thessaloniki (Greece), by her
dentist with two intraoral ulcers in the hard palate. The
lesions had been first noticed 4 months previously and

Correspondence: Dr A Kolokotronis. Department of Oral Medicine and

Pathology, School of Dentistry, Aristotle University of Thessaloniki, Thes-
saloniki 54006. Greece
Received 4 March 1996; revised and accepted 29 April 1996 Figure 1 Two tuberculous ulcers of the hard palate

Figure 2 Photomicrograph showing typical epitheloid granulomas with
Lnnghan’s giant cells and lymphotic infiltrate. (Hematoxylin-eosin: orginal
magni tication x 40)
Figure 3 Chest X-my showing an old tuberculous focus in the right lung
Discussion
Tubercular infection of oral tissues may either be primary
or secondary. Primary infection does occur without sys-
temic infection, but it is extremely rare (Hashimoto and
Tanioka, 1989; Dimitracopoulos et ai, 1991). In the second-
ary type, tuberculosis of the oral cavity is usually coexistent
with pulmonary disease and is primarily a self-inoculation
phenomenon via infected sputum or via the circulatory sys-
tem. Any trauma or existing chronic inflammatory con-
dition can be an entrance for the microorganism to settle
into the oral mucosa (Dahlen et af, 1992).
Primary lesions generally occur in younger patients and
Oral tuberculosis
A Kolokotronis er al
243
secondary lesions may be seen in all age groups: middle-
aged and older persons are more likely to have oral mani-
festations of the disease (Dimitracopoulos rt d,1991).
The pathological lesions of oral niucosa may appear as
ulcers, gummas. nodular granulomas or fissures. The most
frequent lesion is the ulcer and the least common are granu-
lomas and fissures (Dimitracopoulos e/ at, 1991). The
tongue is most often affected. Lesions are found less often
on the floor of the mouth, gingiva, palate and lips. The
lesions alone remain painless in the majority of cases
(Hashimoto and Tanioka, 1989). Some authors believe that
the developed ulcer is very painful especially when the
tongue is involved.
Tuberculosis can be diagnosed in several ways. One way
is the use of bacteriological examination. Thus we can have
the demonstration of acid-fast bacilli in smears taken from
lesions or with the culture of mycobacteria from contami-
nated fluids, exudate from the oral lesions or sections of
tissues to sensitive culture media for 2-5 weeks of incu-
bation. However because of the very small numbers of
mycobacteria in oral lesions, these bacteriological examin-
ations are usually negative (Dimitracopoulos rt al. 1991).
In the present case the diagnosis was confirmed by the iso-
lation of M. ritBrrciriosis in the section of tissues.
Another way to the diagnosis is the histopathological
examination of the lesion. However, the histopathological
examination is not pathognomonic since a similar histopa-
thologic picture is seen in conditions other than tubercu-
losis.
Purified protein derivative (PPD) test and chest X-ray
are mandatory.
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