JICDRO is a UGC approved journal (Journal no. 63927)

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ORIGINAL RESEARCH
Year : 2018  |  Volume : 10  |  Issue : 2  |  Page : 81-87

Oral and periodontal status in patients with tuberculosis in Vidarbha region of Central India


Department of Periodontics and Implantology, Sharad Pawar Dental College, DMIMS (DU) Deemed to be University, Sawangi (Meghe), Wardha, Maharashtra, India

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Prasad Vijayrao Dhadse
Department of Periodontics and Implantology, Sharad Pawar Dental College, Sawangi (Meghe), Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_3_18

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   Abstract 


Context: The purpose of this study was to asses oral and periodontal status of the patients with tuberculosis (TB) at various TB hospitals in Vidarbha region of Maharashtra state, India. Aim: The aim of the present cross-sectional observational study was to assess oral and periodontal status in TB patients at four different centers in Vidarbha region of Central India. Settings and Design: This study was a cross-sectional observational study. Subjects and Methods: The study population consisted of 127 patients aged 13–80 years admitted in wards of four different centers around Sawangi. The soft-tissue lesion and periodontal index were assessed using specialized design proforma. Results: None of the patients reported with healthy periodontal status. Oral lesions were observed in 48.03%, with most frequent sites of involvement were tongue, buccal mucosa, and soft palate. A majority of patients had generalized periodontitis. The prevalence of HIV-positive patient was 7.87%. The mean debris score was 1.35 ± 0.66 and mean calculus score was 1.21 ± 0.60 followed by pocket and clinical attachment level in the range of 1.77 ± 0.56 and 2.81 ± 0.71, respectively. Conclusions: The oral health professional should be made aware to treat the oral lesions in patients with TB with greater caution as the incidence of periodontal diseases and oral lesion, and HIV has become alarmingly higher with these classes of patients.

Keywords: Oral and periodontal status, oral manifestations tuberculous ulcers, tuberculosis


How to cite this article:
Kumar C, Dhadse PV, Agarwal AA, Kale BV, Sigh BS. Oral and periodontal status in patients with tuberculosis in Vidarbha region of Central India. J Int Clin Dent Res Organ 2018;10:81-7

How to cite this URL:
Kumar C, Dhadse PV, Agarwal AA, Kale BV, Sigh BS. Oral and periodontal status in patients with tuberculosis in Vidarbha region of Central India. J Int Clin Dent Res Organ [serial online] 2018 [cited 2019 Aug 20];10:81-7. Available from: http://www.jicdro.org/text.asp?2018/10/2/81/249137




   Introduction Top


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. Less commonly TB is caused by exposure of Mycobacterium bovis through ingestion of unpasteurized infected cow's milk or other atypical mycobacteria.[1] TB is a systemic disease with a worldwide distribution[2] and remains a major health problem in most developing countries with extremely high prevalence in Asian countries.[3] According to conservative estimates, there are 15–20 million cases of infectious TB in the world. This “infectious pool” is maintained by the occurrence of 7.25 million new cases.[3] Although the incidence of this disease is currently decreasing, 95% of the patients with TB live in the developing countries.[3],[4] The incidence of TB in underdeveloped and developing countries thought to be associated with poor hygiene conditions is increasing owing to increased prevalence of HIV infection.[5] India accounts for nearly one-fifth of global burden of TB. Every year about 2.2 million people develop TB in India out of the global incidence of 9.6 million and an estimated 220,000 die from the disease.[3],[6]

The oral manifestations of the lesions due to TB produce a variety of forms and can occur anywhere in the oral cavity. However, they show a predilection for certain areas in the mouth. Periodontal status also seems to be compromised in patients with TB owing to several factors such as poor living conditions, low socioeconomic status, low native resistance, and compromised host response from debilitating or immunosuppressed conditions.[3]

Oral tuberculous lesions may be either primary or secondary. Primary oral tuberculous lesions are extremely rare and generally occur in younger patients associated with cervical lymphadenopathy.[2],[7] The secondary lesions, on the contrary, are more common and mostly seen in older patients. The mechanism of inoculation is not definite, but it is believed that organism enters mucosa through a small surface break.[8],[9] Normally, the intact oral mucous membrane possesses a natural resistance to invasion of M. tuberculosis attributed to the mechanical cleansing action of saliva and food, the presence of salivary enzymes, tissue antibodies, oral saprophytes, and the thickness of protective epithelial covering.[3],[4],[10],[11],[12] Any trauma in the form of abrasion or erosion, or an existing chronic inflammatory condition, may break the natural barrier and an opportunity for organism to settle into the oral mucosa.[12] Carious teeth, extraction socket, periodontal disease, sites irritated by various restorations, and poor oral hygiene have been implicated as probable factors.[9],[10],[11],[12]

The oral organs involved in TB are tongue, soft palate, uvula, gingiva, lips, and salivary glands in descending order of incidence.[13] The lesions of primary disease usually manifest as ulcers, nodules, fissures, tuberculomas, or granulomas.[10],[11],[12] Primary TB of oral cavity is of great clinical significance, since the risk of dissemination during a dental procedure and the possibility that the dental staff may contract the infection, while treating such patients is very high.[2],[12],[14] Purohit et al.[13] have shown that M. tuberculosis can be found in the teeth and gingival mucosa of patients with active pulmonary TB.

The oral lesions of the disease, although not common, occur in various forms.[12] There are a few studies and case reports published on oral and periodontal manifestations of TB in India and overseas. Conversely, scant literature has been published on the oral health status of these patients admitted at various government and private centers around the country. Therefore, the aim of the present cross-sectional observational study was to assess oral and periodontal status in TB patients at four different centers in Vidarbha region of Central India.


   Subjects and Methods Top


A total of 127 patients having TB (primary and secondary) admitted in the Department of Chest disease and TB wards in four medical colleges of Vidarbha region in Maharashtra were examined to assess oral and periodontal status. The four centers were Acharya Vinoba Bhave Hospital (Sawangi), Government Medical College and Hospital (Nagpur), Shri Vasantrao Naik Government Medical College and Hospital (Yavatmal), and Civil Hospital, Wardha. Patients with diagnosed TB were only included in this study.

However, following exclusion criteria were used for patient selection

  1. History or diagnosis of other chest diseases
  2. History of periodontal treatment including prophylactic intervention for past 6 months
  3. History of radiotherapy if any
  4. Pregnant or lactating mothers
  5. Uncooperative or noncompliant patients.


A specially designed case history pro forma was used to gather the details regarding oral and periodontal changes. Prior permission was obtained from the dean of respective medical colleges for the examination of the patients. The study protocol was approved by the Institutional Ethical Committee, and informed consent was obtained from all the patients participating in the study.

Oral examination was conducted in respective wards, using calibrated William's periodontal probe (Hu-Friedy, Chicago, IL, USA) and mouth mirror under proper illumination and infection control conditions. Patients were also evaluated for other lesions in oral cavity such as patches over tongue, gingivae/alveolus, soft palate, buccal mucosa, hard palate hairy tongue, fissures, leukoplakia, candidal growth, blanching, ulcerations, and papillomatous lesions. Oral hygiene and gingival status was assessed using full mouth debris index[14] and full mouth papillary bleeding index.[15] Periodontal status was evaluated by recording clinical attachment level, probing pocket depth (PPD), and gingival recession (GR) at all four surfaces of each tooth, except third molars. The collected data was entered into the standard Microsoft Excel 2007 and analyzed using the SPSS Software version 11.5 Chi-square test and Pearson's correlation coefficient were used for statistical analysis.

Revised National Tuberculosis Control Program criteria for diagnosis of tuberculosis

The basis of diagnosis of TB in the patient was screened through a standardized adopted protocol given by Revised National Tuberculosis Control Program patient reporting to the department with expectoration being present for few days suspecting of TB were examined for fever and/or cough for 2 weeks alongside weight loss or no weight gain. The history was confirmed for patient to remain in contact with suspected or active case of TB following which two expectorations (sputum samples) were sent to laboratory for examination of tubercle bacilli. On reporting two negative of the samples, the patient was treated with the appropriate antibiotic regimen for 10–14 days to clear the existent respiratory tract infection. However, if cough persisted after 2 weeks, a repeat of 2 sputum smears was sent for examination of which even one of the two samples reporting positive was diagnosed of having pulmonary TB, and antitubercular regimen was instigated which was also considered on direct examination of the sputum samples found positive singly or doubly.


   Results Top


The study population consisted of 127 patients of pulmonary TB with a mean age range of study group was in between 13 and 80 years (mean 37.38 ± 15.4 years). There were 95 males (74.8%) and 32 females (25.2%). Currently, 85.04% had no other systemic diseases and only 7.87% of patients were HIV positive and 7.09% had other systemic diseases. Intraoral lesions were observed in 48.03% of the patients [Table 1]. The most frequent oral sites of involvement were tongue, buccal mucosa, and soft palate [Figure 1], [Figure 2], [Figure 3], [Figure 4]. The oral lesions frequently encountered were black patches, hairy/fissured tongue, papillomatous lesion, and candidal lesion [Figure 5], [Figure 6], [Figure 7]. Deep ulceration was observed in four patients and leukoplakia was seen in 2 patients [Table 2], [Figure 6].
Table 1: Demographic data of surfing distribution pulmonary tuberculosis patients

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Figure 1: extent of gingival involvement palatally

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Figure 2: extent of gingival involvement mandibular arch

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Figure 3: palatal involvement on right side

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Figure 4: palatal involvement on left side

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Figure 5: fissures on lip

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Figure 6: leukoplackic lesion over gingiva

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Figure 7: patches over the tongue

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Table 2: Surveying distribution of different types of oral lesion in pulmonary tuberculosis patient

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The average number of teeth present among the study population was 26.38 ± 3.35. The mean debris score in our study was 1.35 ± 0.66 and mean calculus score was 1.21 ± 0.60 [Table 3]. Among the study population, chronic generalized gingivitis characterized by bleeding on probing without loss of attachment was observed in 11 patients (8.66%), while 110 (91.34%) patients were affected by chronic generalized periodontitis. The mean loss of attachment was 2.81 ± 1.36 within the range of 0.85–8.7 [Figure 8]. The mean pocket probing depth was 1.77 ± 0.56 with a range of 0.67–3.53 GR was 1.01 ± 0.93 with the range of 0.00–5.23 [Table 4]. There were only ten patients who were HIV positive. [Table 5] and [Table 6] show the comparative incidence of periodontal status between newly detected, defaulter, relapsed pulmonary TB patients and TB patients and pulmonary TB patients with HIV seropositive, respectively.
Table 3: Periodontal status in pulmonary tuberculosis patients

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Figure 8: poor periodontal status

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Table 4: Comparative analysis of oral lesions between newly detected, defaulter, relapsed pulmonary tuberculosis patients

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Table 5: Comparative analysis of periodontal status between newly detected, defaulter, relapsed pulmonary tuberculosis patients

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Table 6: Comparative analysis of periodontal status between pulmonary tuberculosis patients and pulmonary tuberculosis patients with HIV seropositive

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   Discussion Top


This study was formulated to assess the oral and periodontal status in TB patients. A total of 127 TB patients admitted in the department of chest diseases in private and government TB hospitals at four medical colleges in and around Sawangi (Meghe) and Wardha of Vidarbha region in Maharashtra were examined in the present study. To prevent biases, it was essentially confronted that a single examiner conducted the clinical examination during the course of the study from April 2014 to October 2015.

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. The incidence of oral lesions is 0.05%–5% among TB patients.[1]

In our study, affected patients were in all age groups; the majority of patients were middle-aged and older patients with most patients into their fourth decades [Table 1]. None of the patients had negative chest X-ray, thereby eliminating the possibility of primary oral lesion. This supports the previous view that oral TB is usually a manifestation of secondary TB that is mostly seen at a later age.[2],[3]

Oral lesions of TB are seen in both primary and secondary stages of disease. Intraoral lesions were observed in 48.03% of the patients in our study which is substantially a higher percentage with regard to the available literature.[16] The most frequent oral sites of involvement were tongue, buccal mucosa, and soft palate which is not in line with the reports in the literature. Verma et al. reported that tongue and gingiva are most common sites of infection of oral TB followed by tooth sockets, palate, floor of mouth, lips, and buccal mucosa.[17] Our study revealed oral changes mostly in tongue (37.01%), buccal mucosa (2.36%), and soft palate (2.36%) and gingiva and lip were involved in 0.78%, respectively. The frequency and distribution of oral lesions in TB patients have been mapped by Eng et al. and the most affected sites are ranked.[2] In the present study, 48.03% of patients exhibited active oral-specific lesions predominantly in the form of black patches (18.90%), hairy/fissured tongue (14.96%), papillomatous lesions (5.51%), candidal lesions (3.94%), ulcerations (3.15%), and leukoplakia (1.57%) [Table 3].

Tuberculous lesions may be single or multiple, painful or painless and usually appear as irregular, well-circumscribed ulcer. However, they can begin as nodules, fissures, plaques, or vesicles and then slowly increase in size when they become chronic. There is usually surrounding erythema without induration and commonly satellite lesion may be found.[2] As seen in this article, the tongue and soft palate were most frequently involved. Most of the authors have reported similar observations with regard to the present finding.[16]

The average number of teeth present among the study population was 26.38 ± 3.35, indicating a significant portion of the dentition being present in all TB patients. The mean debris score in our study was 1.35 ± 0.66 and mean calculus score was 1.21 ± 0.60, indicating poor oral hygiene and thus contributing to the incidence of mild-to-moderate periodontitis.

As far as symptoms are concerned, our observation has a high frequency of oral ulcers. The oral involvement includes tongue and soft palate with increasing frequency followed by floor of mouth, buccal mucosa, gingiva, and hard palate [Table 4]. The distribution of oral lesions in our patients was in line with reports of literature.[16],[17],[18]

Direct inoculation commonly involves the gingiva, dental sockets, and buccal folds. One case of nasolabial infection occurred in a physician who administered mouth-to-mouth resuscitation to a TB patient. An outbreak of 14 cases of TB developed after dental manipulation at two community dental clinics had been documented, and 14 out of 15 patients developed intraoral lesions. The dentists who worked in both the clinics were found to have active bilateral pulmonary TB.[2]

Periodontitis is one of the most common oral diseases that affect the human population worldwide with higher prevalence rates.[19] A number of debilitating diseases including TB have been considered as predisposing or contributing factors for the development of periodontal disease.[2],[16] A mild painless-specific type of gingivitis associated with TB was described by Eng et al., who also reported “roentgenographic evidence of enlarged, swollen intertrabecular spaces between and around the teeth.”[2] Papapanou examined more than 1000 TB patients and found a high incidence of characteristic gingivitis which varied in severity and extent proportionately to the pulmonary involvement.[19] A definite association between pulmonary TB and periodontal lesions was also reported by Kramer and Broady. They also reported periodontal bone changes and were later supported by Goadby.[18]

In our study population, chronic generalized gingivitis characterized by bleeding on probing with loss of attachment was observed in 17 patients (8.66%) and surprisingly 110 patients (91.34%) were affected by chronic generalized periodontitis, with mean PPD of 1.77 ± 0.56 in the range of 0.67–3.53 mm and mean clinical loss of attachment was 2.81 ± 1.36 and in the range of 0.85–8.71 mm. Moreover, Shakeel et al. reported mild-to-moderate periodontitis in 40.20% of 87 patients examined.[16] The findings reported in our study were also in line with the studies reported by Ramfjord.[18] The supporting soft tissue and alveolar bone changes evaluated in our study also contributed to GR which was in the range of 0.00–5.23 mm [Table 3].

There have been reports of outbreaks of TB among HIV-positive individuals in health-care institutions in the United States and Europe.[2] Another concern is the occurrence of mycobacterial infection in as a part of AIDS. Ten cases in our study were HIV seropositive which suggests that HIV infection diminishes cell-mediated immune response and thus is a risk factor for the development of TB, either predominantly by reactivation of a latent infection or exogenous infection or reinfection. In our study, however, there were no statistically significant differences in periodontal status and distribution of oral lesions of TB subject with HIV and TB without HIV (P ≥ 0.05) [Table 6].

Although the involvement of oral cavity is relatively rare in TB, clinicians are not sensitized to the disease as a part of differential diagnosis; therefore, there are undoubtedly patients in whom the proper diagnosis and therapy are delayed or the diagnosis is missed entirely. This is particularly unfortunate because TB has become a treatable disease.

This report suggests that none of the patients reported with healthy periodontal status and emphasizes that significant periodontal destruction is seen in the form of mild-to-moderate periodontitis; which can be considered as a common finding in TB patients. A majority of patients required periodontal therapy to revert back tissues to a normal state. This can be attributed to the fact that periodontal pockets may harbor tuberculous bacilli and contribute to the stimulation of pro-inflammatory (innate) cytokines, other inflammatory mediators, and series of matrix metalloproteinases (MMPs) which have a unique ability to degrade fibrillar collagen and other matrix components, thereby causing significant periodontal tissue destruction.[9] In addition, these bacilli can be opportunistically inoculated directly into the oral mucous membrane through minor tears, abrasions, tissue manipulation, and carious lesions, during dental procedures and thus can produce primary tuberculous lesions of the oral cavity.[20] Although secondary oral lesions are usually seen with pulmonary TB, our study reports a substantially higher incidence (48.03%) of distribution of oral lesions in TB patients in the form of fissures and ulcerations with tongue and soft palate being the most common sites of involvement.


   Conclusions Top


In dental clinics, oral health professionals are at higher risk for M. tuberculosi s infection because of coming in close contact with the patient and aerosol spread during the dental treatment procedure. Therefore, attention should be given to the presence of atypical lesions and periodontal disease in TB patients, since early diagnosis and prompt treatment of the same can be tremendously helpful to reduce the risk of patient exposure and prevent spread of infection of this alarmingly dreadful disease. A new approach has to be implemented which would cater to oral health needs of these patients simultaneously safeguarding the health of oral health-care professionals who are placed at higher risk while providing oral health care.

Acknowledgment

We would like to acknowledge all the four centers for their cooperation and Dr. Pavan Bajaj for their help in the study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Shakeel MD, Anjum P, Reddy P, Monica M, Praveen BH. Oral health status of the patients with tuberculosis at the government TB & chest diseases hospital, Andhra Pradesh, India. Int J Dent Clin 2010;2:12-5.  Back to cited text no. 16
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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