Introduction:
Tuberculosis is a well-known infectious disease that accounts for one of the leading causes of death due to infection after HIV (human immunodeficiency virus). It has affected over 1.7 billion individuals worldwide. The disease flourishes wherever there is poverty, crowding, and chronic debilitating illness.
Tuberculosis mainly affects the elderly, and certain conditions like diabetes, malnutrition, alcoholism, immunosuppression increase the risk. Mycobacterium tuberculosis is responsible for most cases of tuberculosis. Mycobacterium Bovis causes intestinal and oropharyngeal tuberculosis contracted by drinking unpasteurized milk. Although tuberculosis affects the lungs (pulmonary tuberculosis), other sites can also be involved (extrapulmonary tuberculosis). Orofacial tuberculosis is a rare extrapulmonary manifestation of tuberculosis.
What Is Orofacial Tuberculosis?
As mentioned above, orofacial tuberculosis is an extrapulmonary manifestation occurring approximately in 0.1% to 5% of all tuberculosis-affected patients. This form is uncommon, and the clinical signs are not specific to establish the diagnosis. Any site in the oral cavity and its associated structures can be involved. Misdiagnosis is expected as the oral lesions can be present before the systemic symptoms. Dentists are generally the first clinicians to witness the signs of orofacial tuberculosis. This type of manifestation can be primary or secondary. The primary form of extrapulmonary tuberculosis affects children and adolescents, while the secondary form affects middle-aged to elderly patients.
What Are the Signs and Symptoms of Orofacial Tuberculosis?
The clinical signs and symptoms vary, and the involvement of soft and hard tissues of the oral cavity is quite common. The signs can be superficial or may involve deeper structures. The various presentations of orofacial tuberculosis include:
A. Tuberculous Ulcer:
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The tuberculous ulcer is a common presentation of orofacial tuberculosis that can be painful or painless, single or multiple, and superficial or deep.
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These ulcers can have an irregular border and vary in shape and size.
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They often develop from a tubercle which then softens to form an oval ulcer with undermining margins.
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Multiple nodules called “sentinel tubercles” can surround the ulcer.
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The tongue is most commonly involved, followed by the floor of the mouth, gums, palate, and lips.
B. Tuberculous Gingivitis:
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The gums (gingiva) may become inflamed, leading to gingivitis. The gingiva appears red and swollen due to the proliferation of the gingival tissues.
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Deeper structures like the bone may not be involved initially. After the disease progresses, tooth structures can be lost, leading to loosening of the teeth.
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The tuberculous gingivitis fails to respond to the conventional gingivitis treatment.
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The lymph nodes of the neck may become enlarged (cervical lymphadenopathy).
C. Tuberculous Infection of Extraction Sockets of Teeth:
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If the infection reaches the extraction site, the healing may get delayed.
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The extraction socket may get filled with infectious tissue consisting of pink and red elevations.
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This outbreak is uncommon, and the cases develop primary tuberculosis before the involvement of extraction sockets.
D. Osteomyelitis of the Jawbones:
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Osteomyelitis refers to infection of the bones. It is a rare scenario, and the mandible (wisdom tooth region is commonly involved) is more affected than the maxilla.
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Tuberculous osteomyelitis can affect adults as well as children.
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The infection is caused through direct transfer from the sputum, through extraction sockets, a break in the mucosa, or through the circulating blood.
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The infection causes necrosis of the jawbones leading to an abscess formation. In severe cases, the jawbone may fracture.
E. Tuberculous Infection of the Maxillary Sinus:
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The maxillary sinus may get involved secondary to pulmonary or extrapulmonary tuberculosis.
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It affects adults, and the symptoms include runny nose, stiffness of the nose, bleeding from the nose, and formation of crusts.
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Nasal polyps may form because of the infection with pus discharge.
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The lesions may resemble a cancerous growth.
F. Tuberculous Infection of the Temporomandibular Joint (TMJ):
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The symptoms of the TMJ involvement resemble that of arthritis or any joint disease.
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This condition occurs in low frequency, and the symptoms usually include stiffness and pain of the joint.
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Muscle spasms may be common, leading to the inability to open the mouth.
G. Salivary Gland Infection (Sialadenitis) Due to Tuberculosis:
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It is a rare condition involving the parotid or the submandibular salivary glands.
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The infection of the parotid glands causes parotitis, which can be localized or diffuse, involving the entire gland.
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The lymph nodes are initially involved and present as a non-painful, slow-growing swelling.
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In the later stages of the infection, pain, pus, abscess, and involvement of the nerves can be seen along with general symptoms like fever, cough, weight loss, etc.
F. Lupus Vulgaris:
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It is the most common form of superficial skin infection seen in patients with sensitivity to tuberculin (protein extracted from Mycobacterium tuberculosis).
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The skin lesions form around the eyelids, nose, lips, cheeks, and ears with a predilection in females.
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Lupus vulgaris can present as ulcers, plaque-like, tumor-like, papules, or nodules. The plaque form is common, accounting for 32% of cases.
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The lesions can be single or multiple, and small lesions can merge into a larger one. The surface of the lesions exfoliates, leaving a central scar.
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Lupus vulgaris resembles apple jelly due to its reddish-yellow or brown color nodules.
How Is Orofacial Tuberculosis Diagnosed?
Orofacial tuberculosis often goes undiagnosed due to its non-specific nature. The approach for diagnosing involves:
A. Understanding the Patient’s Medical History- The clinician asks for symptoms like cough, chest pain, fever, chills, loss of appetite, exposure to HIV, etc.
B. Physical Examination- As the oral lesions are not specific, a physical examination is not enough to confirm the tuberculosis infection.
C. Imaging Techniques- A chest X-ray, CT (computed tomography), and MRI (magnetic resonance imaging) can reveal the systemic infection.
D. Tuberculin or Mantoux Test- It is performed by injecting a purified protein of the bacteria injected intramuscularly. Development of a rash or bump at the injection site after 48 hours to 72 hours indicates the presence of the infection.
E. Microscopic Smear- Sample collected from sputum, oropharyngeal swabs, or biopsy is studied under the microscope to detect the tuberculosis bacteria.
What Is the Treatment for Orofacial Tuberculosis?
The treatment of orofacial tuberculosis is the same as systemic tuberculosis. The first choice of antibiotics includes Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), Ethambutol (E), and Streptomycin. If these drugs are not effective, injectable antibiotics like Kanamycin, Streptomycin, Levofloxacin, and Ofloxacin are prescribed. Orofacial tuberculous lesions also require surgical debridement. The first-line of medications recommended by the WHO (world health organization) has several limitations. New drugs are being developed that are effective and affordable.
Conclusion:
Orofacial tuberculosis is a rare extrapulmonary manifestation occurring in 0.1% to 5% of all tuberculosis cases. A tuberculous ulcer occurs on various parts of the oral cavity, followed by gums, jawbones, maxillary sinus, and temporomandibular joint involvement. Lupus vulgaris is a common finding characterized by ulcers and eruptions on the facial skin. This condition goes undiagnosed due to its non-specific nature. Treatment mainly includes the use of first-line antibiotics recommended by the WHO and surgical debridement of the lesions.
