Keywords
autograft - buccal mucosa - diagnosis - granular ulcer - secondary oral tuberculosis
- treatment
Introduction
Tuberculosis (TB) is a chronic infectious disease caused by Mycobacterium tuberculosis. Around eight million people are affected annually in the world and three million
die every year due to complications of TB.[1]
[2]
[3]
[4] TB is classified clinically as pulmonary and extra pulmonary. Pulmonary TB is the
most common form of the disease while extra pulmonary TB ranges from 10 to 15% of
infected people.[3]
[5]
The lesions of oral TB are not common. Extrapulmonary TB develops mostly develop as
chronic painless ulcers, between 0.05 and 5 cases.[2]
[6] Primary oral TB is distinguished most often in young patients. The secondary oral
TB frequently occurs in middle-aged and advanced adults. M. tuberculosis infects buccal mucosa, gingival mucosa, tongue, lingual frenum, and lips. It is most
frequent in men compared to women.[6]
[7]
[8]
The aim of this study was to report a case of an unusual granular ulcer that did not
heal, chronic, was of irregular appearance with deep depression of 2 cm in diameter,
and was located in buccal mucosa of the area premolar the left mandibular arch of
a 42-year-old woman with secondary oral TB.
Case Report
A 42-year-old female patient who attended a stomatological consultation for oral rehabilitation
treatment underwent a detailed history. She was diagnosed with secondary oral TB.
The patient received antituberculous therapy (ATT) with isoniazid INH, rifampicin
(RMP), etambutol (EMB), and pyrazinamide (PZA), indicating improvement of her systemic
condition but not of her oral clinical condition. At the intraoral clinical examination,
the presence of a granular ulcer without cicatrization, chronic for 3 years behind
the report of irregular edges, with deep depression of 2 cm in diameter and located
in the vestibular mucosa of the premolar area of the left mandibular arch, was observed
([Fig. 1]). The pathological diagnosis confirmed an irregular surface of the ulcer covered
with Trelat granules. Clinically asymptomatic with local lymph nodes are not enlarged.
The anatomopathological study of the sample showed multiple stratified squamous epithelium
with minimal caseous necrosis and Langhans giant cells ([Fig. 2]). The patient was subjected to the clinical and surgical stomatological treatment
protocol. The oral hygiene and the elimination of traumatic factors were provided
and re-evaluated before and after surgical treatment.
Fig. 1 The unusual granular ulcer that does not heal, chronic, of irregular appearance,
with deep depression and located in buccal mucosa of the area premolar the left mandibular
arch.
Fig. 2 The anatomopathological study of the sample showed multiple stratified squamous epithelium
with minimal caseous necrosis and Langhans giant cells (black lines).
The inferior dental nerve and the buccal nerve were anesthetized with 2% lidocaine
with epinephrine 1: 80,000. After anesthesia, a mucoperiosteal flap was performed
with complete Neumann incision from 36 to 42, incising crestally in the edentulous
and intrasulcular zone in the dentate area proceeding to the total excision of the
granular ulcer secondary oral TB in all its extension projecting to 2 mm in healthy
tissue adjacent to the area of the lesion ([Fig. 3]). Check that the edge of the flap is regular. The operative area was washed with
sterile saline solution and consequently, periodontal plastic surgery was performed
in the area of the lesion positioning a subepithelial connective autograft, which
was extracted from the palatal area ([Figs. 4]
[5]). Erythromycin 500 mg/6 h/10 d was prescribed along with ibuprofen 400 mg/6 h/3
d, and oral rinsing with 0.12% chlorhexidine twice a day. After 10 days, the sutures
were removed and the postoperative controls were performed at 15, 30, and 60 days,
with the corrective treatment of the patient ([Figs. 6]
[7]).
Fig. 3 Mucoperiosteal flap was performed with complete Neumann incision from 36 to 42, for
the total excision of the granular ulcer secondary oral tuberculosis in all its extension
projecting to 2 mm in healthy tissue adjacent to the area of the lesion. Check the
edge of the flap is regular. The operative area was washed with sterile saline solution.
Fig. 4 Periodontal plastic surgery was performed in the area of the lesion. A sub epithelial
connective autograft which was extracted from the palatal area and positionating in
the area of the lesion.
Fig. 5 Palatal donor area of the sub epithelial connective tissue with suture.
Fig. 6 Postoperative control at 30 days (front view).
Fig. 7 Postoperative control at 60 days (side view).
Discussion
Oral TB lesions are found only between 0.05 and 5% of cases, developing in most of
them as chronic painless ulcers.[2]
[3]
[4]
[5]
[6] The pathological recognition of this entity is important and its early diagnosis
is necessary.[9]
[10]
[11] TB can infect all parts of the mouth such as soft and hard palate, uvula, buccal
mucosa, gingiva, lips, tongue, maxilla, and jaw.[6]
[7]
[8]
[9]
[10]
[11]
According to published research by various authors two types of oral TB are recognized:
primary oral TB which is more common in young patients and causes enlarged lymph nodes
and secondary oral TB which is registered in adults of middle and advanced age with
M. tuberculosis infecting buccal mucosa, gingival mucosa, tongue, lingual frenulum, and lips.[12]
[13]
[14]
We reported a routine examination in the oral cavity of a 42-year-old female patient,
in whom a granular ulcer that does not heal was observed, chronic, of irregular appearance,
with a deep depression of 2 cm in diameter, located in vestibular mucosa of the premolar
area of the left mandibular arch was present. This finding of secondary TB according
to the clinical manifestation did not present enlarged or painful local lymph nodes
identifying an irregular surface ulcer covered with Trelat granules. The anatomopathological
study of the sample showed multiple stratified squamous epithelium with minimal caseous
necrosis and Langhans giant cells. Additionally, the clinical characteristics of the
lesion aids in differentiating it from other pathologies in the oral mucosa such as
syphilis, histoplamosis, planoepithelial cancer, or recurrent or aphthous stomatitis.[9]
[10]
[11] Our finding is related to that reported by Krawiecka and Szponar et al[14] and Erbaycu et al,[15] who considered that the clinical characteristics of oral tuberculosis differ from
other pathologies in the oral mucosa
According to Kakisi et al, the secondary form is observed more often than the primary
one.[6] The oral focus of infection, M. Tuberculosis, may appear as a result of autoinfection from the sputum with a route of hematogenous
or lymphatic transmission. It is possible that in the majority of patients with TB,
the constant flow of saliva and its antibacterial properties could protect the oral
tissues from the invasion of the bacillus. However, it is also possible that local
traumatisms in the oral cavity may promote infection, as referred by some researchers.[6]
[14]
[15] We could also conclude, according to our study, that secondary oral TB in response
to the invasion of the M. tuberculosis bacillus into the oral tissues is predisposed by local factors such as poor oral
hygiene, prosthetic devices, and inadequate dental treatments.
We consider that the most important aspect of TB treatment is the ATT as a universal
standardized drug therapy. In addition to this, we consider that after the opportune
and differentiated diagnosis of the oral cavity in our case, we evidenced the necessity
of the appropriate stomatological, clinical, and surgical treatment performing the
total excision of the granular ulcer secondary oral TB and the periodontal plastic
surgery. The ATT regimen consists of two phases: the firstline of treatment requires
usually INH, RMP, EMB, and PZA, which were administered for 2 months initially to
continue in second phase for four consecutive months with INH and RMP. Inadequate
management of TB or failure to apply the antibiotic regimen would produce resistance
of the bacillus. A good follow-up of the regimen of adequate antituberculous treatment
could prevent the oral TB. In this regard, we agree with what was reported by Pavlinac
et al,[1] Araj et al,[2] Taute et al,[3] Trinh et al,[4] Nagaraj et al,[5] and Aoun et al.[12]
However, when the lesion is established, it is necessary to consider the diagnosis
of oral TB to determine the appropriate treatment for each patient. In relation to
the surgical treatment of granular ulcer secondary oral TB, the bibliographic evidence
is scarce. However, local topical therapy with antiinflammatory ointments and oral
mucosa protective agents are reported in investigations.[6]
[14]
In our case, in an intraoral clinical routine examination of the patient who underwent
the detailed anamnesis and the clinical examination, it was possible to demonstrate
the need to perform the corrective treatment. The total excision of the tuberculous
granular ulcer was performed along with an immediate periodontal surgery in the area
of the lesion positioning an autograft of subepithelial connective tissue. We agree
with authors such as Chhina,[16] Reino et al,[17] and Zuhr et al,[18] on the use of the subepithelial connective graft for the treatment of plasty of
large mucogingival defects.
We should mention that it was necessary to indicate to the patient about the improvement
of her oral hygiene and the elimination of traumatic factors such as prosthetic devices
and inadequate dental treatments.
The aim of this presentation was to report a case in a routine examination, of a granular
ulcer that does not heal, of irregular appearance with a deep depression of 2 cm in
diameter located in the vestibular mucosa of the premolar area of the arch, left mandible,
of a 42-year-old female patient. Surgical excision of the tuberculous granuloma was
performed in its entirety with a 2 mm projection to adjacent healthy tissue and consequently,
periodontal plastic surgery in the area of the lesion positioning an autograft of
subepithelial connective tissue extracted from the palatal area and the respective
postoperative controls.
Conclusion
We considered it important to perform the detailed clinical examination of the patient
with granular ulcer secondary oral TB, with the timely clinical, surgical, and stomatological
treatment such as the surgical excision of the lesion and consequently, the periodontal
plastic surgery with autograft of subepithelial connective tissue extracted from the
palatal area. It reported optimal results in the improvement of oral health, function,
and comfort of the patient treated at 15, 30, and 60 days, respectively. In all the
time of study, we did not find recurrence of the pathology.
