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Tuberculosis of the oral cavity: A systematic review

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Eur J Oral Sci 2010; 118: 103–109 Ó 2010 The Authors.
Printed in Singapore. All rights reserved Journal compilation Ó 2010 Eur J Oral Sci
European Journal of
Oral Sciences

Review
Ourania K. Kakisi1, Argiro S.
Tuberculosis of the oral cavity: a Kechagia1, Ioannis K. Kakisis1,
Petros I. Rafailidis1,2, Matthew
systematic review E. Falagas1,2,3
1
Alfa Institute of Biomedical Sciences (AIBS),
Athens, Greece; 2Department of Medicine,
Kakisi OK, Kechagia AS, Kakisis IK, Rafailidis PI, Falagas ME. Tuberculosis of the Henry Dunant Hospital, Athens, Greece;
3
Department of Medicine, Tufts University
oral cavity: a systematic review. Eur J Oral Sci 2010; 118: 103–109. Ó 2010 The School of Medicine, Boston, MA, USA
Authors. Journal compilation Ó 2010 Eur J Oral Sci

The recent increase in the incidence of tuberculosis, combined with an emerging global
resistance to antituberculous drugs, warrants an increased awareness of the involve-
ment of Mycobacterium tuberculosis in persistent or atypical lesions in the oral cavity.
We sought to review the published reports of mycobacterial infection of the oral cavity
found in the literature in otherwise uncompromised patients, from 1950 to the present
day, and analyzed the documented manifestations. M. tuberculosis infects all parts of
the mouth (soft and hard palate, uvula, buccal mucosa, gingivae, lips, tongue, maxilla,
and mandible) more often in men than in women, appearing predominantly in the
form of ulcerative lesions. It was found as a secondary infection in 58% (54% Matthew E. Falagas, MD, MSc, DSc, Alfa
pulmonary, 4% extrapulmonary) of patients and as a primary infection in 42% of Institute of Biomedical Sciences (AIBS), 9
patients. Carcinomas are found to co-exist in the same lesion site in 3% of patients. In Neapoleos Street, 151 23 Marousi, Greece
approximately 50% of patients, an oral manifestation of TB has led to the diagnosis of
Telefax: +30–210–6839605
a previously unknown systemic infection, which resulted in a timely and effective E-mail: m.falagas@aibs.gr
treatment. The investigation for tuberculosis should therefore be actively pursued in
the dental surgery. Diagnostic work-up for systemic involvement and control of Key words: cases review, extrapulmonary, oral
tuberculosis, primary
healthcare-associated spread is important, while therapeutic options are still consid-
ered adequate. Accepted for publication February 2010

Tuberculosis (TB) is still among the most life-threatening
infectious diseases, resulting in high mortality in adults
(1). With an incidence of 139 per 100,000 (in 2007) active
Mycobacterium tuberculosis infections globally, it is
estimated that two billion people (i.e. one-third of the
worldÕs population) have been in contact with the TB
bacillus. A significant proportion of patients (15–25%)
(1) exist in whom the active TB infection is manifested in
an extrapulmonary site (2). Moreover, the emergence of
drug-resistant TB has recently raised serious concerns.
Tuberculosis is a frequent cause of missed or complicated
diagnosis in general medical settings (3). Healthcare
workers, including dentists, are at the frontline and can
make an important contribution to the control of this
infectious epidemic (4, 5).
Oral TB has been considered to account for 0.1–5% of
all TB infections, based on reviews published before
1950. 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 (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 (6).
Unfortunately, the magnitude of this phenomenon in
immunosufficient hosts has not been studied in detail.
This review therefore seeks to assess the manifestations
and symptoms of TB in the oral cavity of non-
immunocompromised hosts, as documented in the liter-
ature published in English to the present date. However,
its scope is not to estimate the true incidence of oral TB.
A systematic analysis of reported cases, such as the
present study, aims only to serve as a descriptive tool, in
a grey area where misdiagnosis and late treatment often
adds to the suffering of inflicted individuals. It is true
that the dental identification of M. tuberculosis has the
potential of serving as an important aid in the first line of
control for this dangerous, and often fatal, disease.
Study selection criteria and data extraction
We searched PubMed and Scopus (1950–November
2009) for clinical trials, case reports, and case series of
the documented presence, morphology, and treatment of
M. tuberculosis infection in the oral cavity. The main
search involved mesh terms associated with M. tubercu-
losis AND oral cavity. Additional searches involved the
use of different localizations (such as lingual or buccal
mucosa) AND tuberculosis as well as relevant searching
of the references of all retrieved articlesÕ for possible
inclusion.
A study was eligible for inclusion in the review if it
reported an oral presentation of TB in a non-immuno-
compromised patient and included data on investigation,
and subsequent treatment and outcome. Case series and
case reports were eligible for inclusion. Cases of head
104 Kakisi et al.

and neck manifestations involving the salivary glands,
parotid gland, larynx, oropharynx, tonsils, temporo-
mandibular joint, sinuses, and ears were not included in
this review. Patients who were immunocompromised by
the HIV virus, cancer diabetes or chemotherapy were
excluded. Included, however, were studies that reported
the simultaneous presence of TB and oral cancer in the
same lesion site. Reports that were published as confer-
ence abstracts or in languages other than English were
also excluded.
Data such as patient demographics, history of contact,
main clinical manifestations, investigation, and treat-
ment and its outcome with a follow-up period, were
extracted and tabulated.
Results
The literature search yielded 379 case reports, of which
201 were not in English, 25 concerned the head and neck
regions (which were excluded in this review), and 10 were
reports of immunocompromised patients. Eighteen arti-
cles were not available. The remaining 125 case reports
constituted the main body of this review. The findings
consisted of 110 unique case reports, 13 case series
(including 2–7 patients), and two case series of 15+
patients. In total, 145 patients from case reports and
small case series were included in the analysis; larger case
series (7, 8) were analyzed in comparison but were not
tabulated.
Demographics of infection and localization
The mean age of patients presenting with oral cavity TB
was 37.3 yr, of whom 17% were children (age-range 1–13
yr) and 8% were 60–83 yr of age. Sixty-five per cent of
the patients were male. Fifteen per cent of patients pre-
sented with a positive family, or work-related, history of
contact with TB, and only 6% had already been diag-
nosed with TB. Interestingly, heavy tobacco use (either
smoking or chewing) was associated with 27% of the
reported cases of TB.
Of all reports of oral TB in the English literature, 44%
originated from Asia (where the majority were from
India followed by Turkey), 27% originated from Europe
(mainly the UK), 12% were from North America, 3%
were from South America, 6% originated from Japan,
3% were from Africa, and 5% were of unknown origin.
The case reports were tabulated and analysed
according to main or initial site of presentation of the
oral TB lesion (Supporting Tables S1–S5). The hard
palate is the rarest of all sites of oral involvement and
was cited as the main or initial site of presentation of the
oral TB lesion in 5% of the case reports (Table S1). The
soft palate was cited as the main or initial site of pre-
sentation of the oral TB lesion in 8% of the case reports
(Table S1). The lips, buccal mucosa, and gingivae were
cited as sites of infection in 9%, 8% and 16%, respec-
tively, of the case reports (Tables S2, S4). The most
common site of infection with M. tuberculosis was the
tongue (32.4%) (Table S3) and the second most common
site of infection was the mandible (21.4%) (Table S5).
Two case reports cited the uvula as the main or initial site
of presentation of the oral TB lesion (Table S1).
Analytic epidemiology of tissue localization and clin-
ical manifestations are summarized in Table 1. Tongue
TB was the most frequent manifestation in case reports,
while, interestingly, it was found in 0.8% of total tongue
pathologies in a region of endemic TB, based on a
sample of 1,250 ear, nose and throat (ENT) patients (9).
In our present review, the buccal mucosa was found to be
more commonly associated with primary oral infection,

Table 1
Demographics, main morphology, and detection rate of traditional investigations according to different localizations of Mycobacterium
tuberculosis in the oral cavity

Mean Principal Pulmonary Mantoux Culture AFB

Localization age (yr) Gender lesion (%) co-infection, % (+), % (+), % (+), % Cure%

Hard palate
7/145 43.5 M=F Ulceration (75) 50 80 67 67 100
Soft palate
12/145 40 M=F Ulceration (58) 25 86 33.3 30 75
Buccal mucosa
12/145 42 M92% Swelling (58) 38 100 100 60 92
Lips
13/145 44 M69% Ulceration (85) 69 85 23 37.5 100
Gingivae
23/145 29* F65%* Ulceration (64) 54.5 70 50 60 84
Mandible
31/145 25.5* F53% Swelling (81) 56 79 63.2 35.7 78
Tongue
47/145 45 M81% Ulceration (84) 55 76 70 70.4 97.5

All areas
145/145 37 M65% Ulceration (55) 54 74 59 52.3 83.5

M, male; F, female.
*Significant difference of mean values ± standard deviation, among oral areas.
Localization: total number of positives/total number of included patients, in different sub-areas.

Table 2
Macroscopic manifestations of oral tuberculosis cases
(1950–2009)
Manifestations of Percentage of
oral tuberculosis lesions reported patients
Ulceration 55 (80/145)
Swelling 24 (34/145)
Discharge (with or without fistulae) 10 (14/145)
Nodules (tubercles) 8 (12/145)
Extraction socket involvement 8 (11/145)
Granulomatous plaques, growths, indurations 5 (7/145)
Diffuse inflammation 4 (5/145)
Collision masses 2 (3/145)
in agreement with previous documentation (8) of one
case series from Italy of 42 patients with oral TB. The
lips, by contrast, were found to be more commonly
associated with secondary infection. Gingivae and the
mandibular bone were more frequently infected with
M. tuberculosis in females than in males and those of
younger ages (range 7–46 yr and 3–76 yr respectively), in
comparison to the other sites of infection.
Morphology of lesions
The primary manifestations of a TB infection in the oral
cavity are listed in Table 2. Ulcers (55%) were present
more commonly as single, rather than multiple, with
indurated, ill-defined margins and a hard necrotic base
(58%) or covered with greyish or yellow slough (42%).
The appearance of satellite lesions was very rare (one
patient) (10). Swellings were rarely associated with scales,
scabs (11) or papules and the appearance of clefts
(12) (9%) and were usually (92%) non-tender, warm,
expansile, and fixed to the oral tissue. Nodular masses
measuring from 1 mm to a few cm were found in 8% of
patients. Diffuse lesions (4%) appeared as a granulom-
atous enlargement of the gingivae (two patients) (13, 14),
confluent erosions (one patient) (15) or diffuse papulae in
the oral mucosa extending to one or more oral regions
(one patient) (16). Macrocheilia were found in two
patients (17, 18).
Mandibular osteomyelitis presented most commonly
as a swelling with signs of atypical osteitis or periodontal
disease with vertical bone loss or destructive osteolysis;
the discharge of blood, exudate or pus was also described
(14/31 of patients), through either the sinuses or the
tooth sockets. In one patient (19), the discharge of
spicules of bones through the gums was reported.
Symptoms of infection
Among the 145 patients with oral TB, five were described
as asymptomatic (one of whom was discovered by acci-
dent, during dental treatment, to be infected with TB)
(20). Pain and odynophagia (pain while eating) were the
most common local symptoms and accounted equally for
15% of all cases accompanied by dysphonia (difficulty in
speaking; 2%). Other symptoms included a burning
sensation, reflux, excessive salivation, halitosis, and
Oral tuberculosis systematic review 105
intra-oral bleeding. A functional disability of the tongue
was found in two patients (10, 21). Cutaneous symptoms
included a scaly rash on the head and trunk (15), one
case of erythema nodosum (22), and lesions on the neck,
wrist, and body (16). Skeletal symptoms (23, 24) were
reported in conjuction with another extrapulmonary
localization. Symptoms that warranted emergency care,
such as lethargy, accelerated loss of weight, severe
haemoptysis or vomiting, dyspnoea, and rapid deterio-
ration, were present in 8/145 (5.5%) of patients. Twenty-
five per cent of these symptoms were reported in patients
with primary oral TB, and in particular of the gingivae
(25) and hard palate (26).
Tuberculosis-specific symptoms have aided clinicians
significantly towards the suspicion and diagnosis of a
mycobacterial infection. In 37% of individual cases,
patients suffered from (in this order of frequency) weight
loss, anorexia, intermittent fever, productive cough,
malaise, cachexia, night sweats or chills. Thirteen of
these patients (9% of the total) lacked a documented
pulmonary infection, while three patients (2%) mani-
fested TB-specific signs alongside an extrapulmonary
focus of infection. The enlargement of regional and neck
lymph nodes was not specific. Primary oral disease usu-
ally involved the submandibular nodes (11/24 patients),
while more than one lymph node area (submandibular
and submental) was affected in 13/57 patients.
In mandibular osteomyelitis, trismus and hypaesthesia
were described; whereas external trauma, such as frac-
ture (27, 28) or extraction (19, 29–34), seemed to favour
or follow the onset of TB in 29% of patients.
Duration of symptoms and previous treatment
In 64% of the patients, symptoms had been present for
< 6 months (mean 6.2 months; range 1 d to 5 yr). Forty-
three of 145 patients had previously received treatment
with various antibiotics and/or antifungal agents,
whereas 22 of 145 patients had received other medications
such as corticosteroids (5/144), antihistamines, anal-
gesics, local anaesthetics or multivitamins. In one patient,
diffuse spreading of infection was observed after the
use of corticosteroids (26). All the above patients were
referred for investigation as Ônon-healingÕ or unchanged
following treatment with previous medication.
Investigations
Tuberculin skin testing (Pure Protein Derivative, Heaf or
Tine Test) was performed in 43% of all patients and was
positive in 76% (a mean reaction diameter of 32 mm
measured in 24 or 48 h). These were 53% patients with
primary mouth TB. Only 7% (10/145) of patients had
been previously vaccinated with the bacille Calmette–
Guérin (BCG) vaccine. Laboratory investigations
included full blood counts and liver function tests, while
the erythrocyte sedimentation rate (ESR) was reported in
39% (57/145) of patients and was elevated in all but
three, with a mean of 59 mm in the first hour. Investi-
gation for syphilis was performed in 15/145 patients and
for HIV in 43/145.
106 Kakisi et al.
All reports but one (35) described an incisional or deep
tissue (punch) biopsy that was pathognomical of
M. tuberculosis infection, with either the presence of
caseation (74/145 patients) or no caseation but distinc-
tive epitheloid structures (Giant or LanghansÕ cells) (34/
145 patients). In three patients (3%) TB was found to
co-exist with oral cancer: one was a collision mass of the
buccal mucosa and an adenoid cystic carcinoma that
had not healed by traditional antituberculous therapy
after 6 months (36); and two were of a tubercular
osteomyelitis co-existing with a central mucoepidermoid
carcinoma (CMEC) of the jaw (37, 38). A fine needle
aspirate (FNA) of tissue was performed in 10/145
patients (40% positive). In 9/145 patients a complimen-
tary lymph node biopsy (conventional or FNA) was
performed (100% positive).
Radiographic means documented bone resorption
and/or osteolysis in the mandible (22%), the mandibular
alveolar ridge (1%), the maxilla (1%), and the hard
palate (< 1%). Sequestrae were discovered in 5/31
patients, periosteal reaction in 5/31, and erosion of the
cortex in 8/31. A further investigation with a technetium-
99m methylene diphosphonate (Tc-99 MDTP) scinti-
gram was sought (5/34 studies of suspected skeletal TB).
Primary and secondary oral TB
Primary oral lesions were found in 42% and secondary
TB in 58% (of which 4% extrapulmonary) of patients
reviewed. Only in one patient was a radiographic
investigation for pulmonary co-infection not per-
formed. This is in contrast to two large case series (15–
42 patients) that documented 93.3% (7) and 79.4% (8)
of secondary oral TB. This, however, may be caused by
the publication bias of reporting a greater number of
ÔrarerÕ forms of TB, like primary cases. Secondary oral
TB has been previously referenced in the vast majority
of included case reports as being prevalent in elderly
patients, with primary infection limited to younger
individuals (based on editorials and expert opinion).
We failed to identify such a trend in the total studies
investigated.
Diagnosis: traditional staining and culture
Microbiological identification for Mycobacteriae was
ordered in a total of 128/145 tissue samples following
biopsy. Fifty-three per cent of immediate acid-fast bacilli
(AFB) stains of the lesion were positive for M. tubercu-
losis. The cultures performed (59/145) were positive for
M. tuberculosis in 59% of samples, for Mycobacterium
bovis in 3%, and negative for Mycobacteria in 38%,
while the culture was negative with a positive stain only
in four samples. Mycobacterium avium intracellulare is
not found in the oral cavity of immunosufficient hosts in
the literature. Antimicrobial susceptibility testing was
ordered in only 15 of 145 studies, and there was one
documented resistance to ethambutol (29). Where pul-
monary infection was documented, sputum identification
had initially been sought in 73/145 samples and was
negative by stain and/or culture in 12/73.
Staining and culture seem to be even less sensitive in
sites such as the soft palate and lips (Table 1). Sensitivity
is considered to be influenced by time to presentation
since hypertrophic lesions with acanthosis and hyper-
keratosis (21) complicate adequate sampling of already
paucibacilli-sites. However, this hypothesis (time to
presentation in regard to the AFB result), when tested in
our 128 reviewed cases with an AFB result, was not
significant.
Diagnosis: molecular methods
The polymerase chain reaction (PCR) was conducted in
15/145 patients directly on tissue (mucosa and bone)
specimens that were formalin-fixed, paraffin-embedded
sections of the biopsy (14/15) or on pharyngeal lavage
samples (1/15) (39). Nucleic acid testing was directed at
the 6,110 insertion sequence of M. tuberculosis (14, 15,
40, 41) or the 65 kDa heat shock protein (42). The PCR
analyses identified as positive, otherwise found negative
samples in 6/15 cases and confirmed the positive AFB or
culture result in 5/8 patients. One PCR test (43) was
conducted as a standalone identification and was positive
for M. tuberculosis. Three PCR test results were negative
in culture-positive specimens of bone (44), with dissem-
inated cutaneous TB affecting the soft palate (16) and lip
(45). Two PCR test results were positive and provided
the definitive diagnosis for M. tuberculosis because the
tissue biopsy was not conclusive (15, 42).
Treatment and outcome
In the majority of cases direct curettage and periodontal
treatment with tooth extractions, scaling and root plan-
ing was performed. Upon confirming the diagnosis of
TB, first-line antitubercular therapy (ATT) was initiated
in 90.3% of patients, with the mean duration of drug
treatment from available reports ranging from 6 to
15 months. Treatment consisted of multiple combina-
tions of pyrazinamide (P), ethambutol (E), rifampin (R),
isoniazid (I), morfazinamide (M), and streptomycin (S)
or para-amino-salicylic acid (PAS). The predominant
combination was that of 2 months of P-I-R-E and
4 months of I-R. In 16% of patients with oral TB,
appropriate surgery was performed. In two patients (32,
46) a sequestrectomy was the only therapy for a
mandibular TB osteomyelitis.
Cure was achieved by resolution or healing of the
affected tissue in 84% of patients, with a mean follow-up
of 8 months. Recurrence was observed in one case (18) of
an upper lip infiltration with pulmonary co-infection
(three recurrences before resolution). In one patient (36)
the tuberculous swelling did not heal after 6 months of
standard ATT, and further biopsies revealed a co-exist-
ing adenoid cystic carcinoma. In the three patients with
simultaneous TB and oral cancer, follow-up was
maintained in two and lost in one (37). One study (47)
reported multiple aphthous ulcerations as an adverse
reaction to the antituberculous tablets directly on the
oral mucosa, with 3–5 d of ulcerative lesions adding to
the discomfort of the patient. Four deaths occurred (3%)

and were attributed to extensive pulmonary disease
caused by haemoptysis and dyspnoea (three patients)
(48–50) or tubercular meningitis (51). Table 1 presents
the analysis of cure rates according to localization inside
the oral cavity, where no differences were observed.
Discussion
This review elucidates the most prevalent and rarer
manifestations of oral TB that are identifiable to the
dental practitioner and physician macroscopically during
a typical consultation. It is notable that 94% of patients
were unaware that they were infected with TB. Ulcers
typically demonstrating a distinctive necrotic or
slough-filled base and irregular borders, and that are
unresponsive to antibiotic treatment (30%) or to corti-
costeroids (4%), should be immediately investigated for
TB. It is important for dental professionals to actively
collaborate with a pneumonologist and a microbiologist
to achieve a clear and concise diagnosis, because labo-
ratory work-up, immunodeficiency testing, a pulmonary
X-ray, and a tuberculin skin test are imperative when
there is the slightest suspicion of TB. A false-negative
tuberculin skin test was found in 28% of patients.
Dentists are urged to seek the presence of TB-specific
signs (present in 37% of the patients in the present cases-
review) and to conduct a careful patient history to
establish previous contact (positive in 15% of patients).
Caution is warranted in the evaluation of overlapping
symptoms, such as weight loss, that can be falsely
attributed to oral pain and odynophagia. Productive
cough, chest pain, and intermittent fever are more
specific signs of active TB.
Pathophysiology
This review reports a ratio of 42% primary vs. 58%
secondary oral TB in the English language literature. The
cleansing effects of saliva, the relative paucity of lym-
phoid tissue in the tongue, and the antagonist oral
commensals (52) are all reasons for the low levels of
mycobacteria in the oral cavity. However, pulmonary
involvement results in an increased concentration of
M. tuberculosis in the mouth, while a breach in the oral
mucosa (53), as a result of tobacco use, traumatising
dentures or poor oral hygiene, increased mycobacterial
virulence; alternatively, close family contact could also
explain primary infection. The BCG vaccination was
also reported as a possible precursor for oral cavity
osteomyelitis in two studies (23, 54) (hard palate and
mandible) of children vaccinated at birth.
TB in healthcare workers
Healthcare-associated infection with oral TB was also
highlighted, with two cases of secondary oral TB
recorded in healthcare workers who came into contact
with TB-infected (49) and HIV-infected (55) patients,
and one case of primary oral TB occurred among 15
infections inflicted by a dental professional who was
Oral tuberculosis systematic review 107
actively infected with TB (56). Evidently, direct inocu-
lation is possible via dental manipulation and contami-
nation in the dental surgery. Procedures carried out in
dental surgeries, especially ultrasonic scaling and treat-
ments using air-turbines, could potentially contaminate
the air with bacteria via aerosol, compared with the
levels of bacteria in air before treatment, and thus might
facilitate transmission of TB (57).
TB diagnosis for the dental practitioner
The observed decreased sensitivity of traditional methods
for detecting Mycobacteriae in oral lesions (52% sensi-
tivity for AFB staining and 58% sensitivity for culture) is
an issue that sometimes impairs dentistsÕ decisions to
refer a patient for testing. Indeed, lesions of the lips and
soft palate demonstrate especially low sensitivities in
staining and in conventional culture. The heralded
rapidity and increased sensitivity of conventional nested
or reverse transcription (RT) PCR can be a successful
alternative in the identification of oral M. tuberculosis.
One study (52) has found that the detection rates of
oral Mycobacteria increased from 2–17% in culture to
89–100% in PCR. However, failure of the PCR to detect
Mycobacteria was still recorded in 3/15 studies, while
distinction between M. tuberculosis and M. bovis by oral
tissue PCR is still considered problematical.
Microbiological identification is deemed imperative for
the determination of antimicrobial resistance. Until now,
multidrug resistant strains have not been recorded in
patients with oral TB. Antituberculous resistance could
lead to therapeutic failure. Failure to heal following
treatment with antituberculous drugs can also be caused
by cancer co-existing with TB (36) in oral tissues. The
incidence of TB co-existing with oral cancer (3% of
cases) in this review is markedly high.
Investigation for an oral TB lesion should almost
universally include a tissue biopsy, which has been found
to be 88% specific in published case-reports. Biopsy
analyses are used to rule out systemic diseases such as
WegenerÕs granulomatosis, sarcoidosis, BehcetÕs disease,
CrohnÕs disease, Melkersson-Rosenthal syndrome, and,
of course, oral cancer. In addition, it seems that diag-
noses related morphologically to orofacial syndromes,
such as granulomatous cheilitis or chronic aphthous
syndrome, should not be hastily adopted without a full
investigation. In one case series of 28 patients with
macrocheilia (58), only 46.4% had granulomatous chei-
litis, while a significant 21.4% were confirmed as cases of
TB of the lip.
Radiographic control for the spread of infection in
bone tissue is important. In one large study, tubercular
osteomyelitis of the head and neck occurred not only in
the mandibular bone but also in the cervical spine (67%
of cases) (59). This finding elucidates the importance of
checking for other relevant manifestations of the disease,
apart from the lungs.
The high resolution rates observed in the reports
analysed for this review suggest that treatment is effec-
tive, because, until now, multidrug-resistant TB strains
have not been reported in the oral cavity. The various
108 Kakisi et al.
antitubercular medications available are generally con-
sidered as safe with mild-to-moderate side effects, such
as flushing, nausea, hepatotoxicity, and neurotoxicity;
however, when monitored by attending pneumonolo-
gists, side effects can be treated.
Concluding remarks
The limitations of this review include the language
inclusion criteria, because a large number of studies,
which could add to the variability of the results, are not
published in English. The simultaneous analysis of case
reports from the 1960s or 1970s and those published
recently may also appear to be disproportionate. In this
review, adjusting only for the respective publication rates
for each country and year would have enabled a general
estimate of oral TB incidence. One should also bear in
mind the publication bias of the reporting of more ÔrareÕ
forms of oral TB in the literature, such as primary
infections or oral cancer co-existence. However, its
constant documentation in the literature demonstrates a
need for awareness of this clinical entity and caution for
the years to come, especially in view of the fact that
drug-resistant forms of TB are appearing with increasing
frequency in developing countries.
Physicians and dental practitioners are urged to
include TB in the differential diagnosis of a persistent
lesion of the oral mucosa that is non-responsive to
therapy, especially when systemic symptoms, indicative
of TB, are present. A complete microbiological investi-
gation and biopsy should be carried out and the patient
subjected to radiographic and laboratory tests. Early
diagnosis and prompt treatment are considered impera-
tive in controlling the spread of this lethal disease in
dental and medical settings.
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Supporting Information
Additional Supporting Information may be found in the online
version of this article:
Table S1. Clinical and epidemiological data of soft palate,
uvula and hard palate-associated tuberculosis patients in the
English literature (1950–2009).
Table S2. Data of lip and buccal mucosa-associated tuberculosis
patients.
Table S3. Data of tongue-associated tuberculosis patients.
Table S4. Data of gingivae-associated tuberculosis patients.
Table S5. Data of mandible or maxilla associated tuberculosis
patients.
Data S1. References to articles referred to in Tables S1–S5.
Please note: Wiley-Blackwell is not responsible for the content or
functionality of any supporting materials supplied by the authors.
Any queries (other than missing material) should be directed to the
corresponding author for the article.