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Oral Cavity and Leprosy Review Article Oral cavity and leprosy Shambulingappa Pallagatti, Soheyl Sheikh, Anupreet Kaur, Amit Aggarwal, Ravinder Singh Department of Oral ABSTRACT Medicine and Radiology, M. M. College of Dental Although leprosy involves the oral cavity in up to 60% of the patients, examination of the oral cavity Sciences and Research, in leprosy clinics or oral health science clinics is often neglected. Oral involvement in leprosy can Mullana, Ambala, broadly be divided into non-specific and specific lesions. In this review, we discuss various oral Haryana, India manifestations in leprosy patients so as to increase the awareness about this aspect among dermatologists and dental surgeons. Key words: Leprosy, non-specifi c, oral involvement, specifi c INTRODUCTION EPIDEMIOLOGY AND PATHOGENESIS Leprosy is a chronic multisystemic disease caused by Mycobacterium leprae, wherein the Involvement of the oral cavity in leprosy is variable, clinicopathological presentation is determined seen in 19–60% of the patients,[5,6] with involvement by the complex interaction between the being more common in multibacillary disease invading organism and the immune status of the compared with paucibacillary leprosy.[7] Recently, individual. The most common organs involved Martins et al. observed that leprosy-related lesions are the skin, monocyte–macrophage system are not present in patients undergoing treatment, and peripheral nervous system. However, a probably due to response to multidrug therapy.[8] mild to moderate degree of infi ltration is seen in many other organs and organ systems M. leprae has an affi nity for the cooler regions of like the liver, kidneys, eyes, oral mucosa, the body. This to an extent explains the preferential Access this article online lymph nodes, bones and joints and gonads. sites involved in leprosy, i.e. the peripheral nerves [9] Website: www.idoj.in Historically, destructive changes in facial bones and the nasal mucosa. Hastings et al. confi rmed this hypothesis by observing that the bacterial DOI: 10.4103/2229-5178.96700 formed the basis for diagnosing leprosy among Quick Response Code: index was much higher in skin with a mean surface skeletons excavated from the site of a leprosy temperature of 32.5°C compared with skin with a hospital in Denmark that existed between mean surface temperature of 33.46°C. Scheepers 1250 and 1550.[1] Infl ammatory changes of the et al. found the hard palate to be the most frequent hard palate, varying from small pits near the site of oral involvement in leprosy, followed by transverse palatal sutures to palatal perforation the soft palate, labial maxillary gingival, tongue, along with atrophy of the anterior nasal spine lips, buccal maxillary gingival, labial mandibular and alveolar process of maxilla were seen gingival and the buccal mucosa. This was found to [2] Address for in a majority of these specimens. Together, correlate with their mean surface temperatures.[10] correspondence: these formed the triad facies leprosa that was Lower the mean surface temperature, higher was Dr. Anupreet Kaur, highly suggestive of leprosy. Involvement of the frequency of involvement. The anterior palate, Department of Oral the hard palate suggests that lesions of the Medicine and Radiology, which may be involved in up to 75% in cases with oral mucosa occur in patients with advanced M. M. College of oral lesions, shows a mean surface temperature Dental Sciences and disease. Involvement of oral mucosa in leprosy of 27.4°C. Mouthbreathing is commonly seen in Research, Mullana, is considered to be of greater epidemiological patients with lepromatous leprosy due to nasal Ambala, Haryana, India. signifi cance as this, along with nasal mucosal obstruction and stuffi ness. This lowers the mean E-mail: anupreet.mds@ involvement, may constitute an important surface temperatures, especially over the dorsum gmail.com source of transmission of bacilli.[3,4] of the tongue and the hard and the soft palate.[11,12] Indian Dermatology Online Journal - May-August 2012 - Volume 3 - Issue 2 101 Pallagatti, et al.: Oral cavity and leprosy Pinkerton in 1932 described the various pathological alterations seen Table 1: Non-specific and specific oral lesions seen in the nasal and oral mucous membranes following mycobacterial in leprosy invasion.[13] Initially, there is congestion of the mucosa followed Leprosy–non-specific lesions by infi ltration and formation of nodules, which may ulcerate. In Enanthem of palate or uvula advanced disease, complications arise due to fi brosis, leading Leprosy-specific lesions to deformities, gross disfi guration and functional abnormalities. Lips MORPHOLOGY Flat-topped nodules Macrocheilia Microstomia The oral lesions in leprosy are slow to progress and are usually asymptomatic. The spectrum of lesions may vary Tongue from relatively non-specifi c ones like enanthem of palate or Multiple superficial ulcers uvula, which, on histopathology, may show no changes or Mild glossitis non-specifi c infi ltrate to more specifi c lesions like papules, Loss of papillae nodules and ulcers, which may show bacillary positivity.[14] Fissured tongue Table 1 enumerates the various non-specifi c and specifi c Nodules on anterior tongue lesions seen in the oral cavity in leprosy. However, no lesion Atrophy can be referred to as pathognomonic for leprosy. The number Pavement-like appearance of oral lesions increases with age. Scheepers et al. report the Buccal mucosa prevalence of oral lesions to be higher among males compared Diffuse infiltration with females.[15] Females tend to present at a younger age, Papulonodules and ulceration probably because of the greater cosmetic concern. The same Pale mucosa authors observe the presence of family history of leprosy to be Hard and soft palate a signifi cant factor in determining the severity of the oral lesions. Loss of shininess of mucosa Erythematous papules Leprous involvement of the lips may present as macrocheilia, Nodular sub-mucosal infiltrate [16] presence of flat-topped nodules and microstomia. The Palatal ulceration swollen and rigid appearance of the lips may be marked and Palatal perforation hence cosmetically quite troublesome. In a study by Handa Uvula and fauces et al., leprous macrochelia was seen in 10.7% of the 28 patients Miliary papules and nodules presenting with chronic macrocheilia.[17] The tongue may be Triangular deformity of fauces involved in 17–25% of the cases.[18,19] Commonly observed Dental lesions include multiple superfi cial ulcers, mild glossitis, loss Gingivitis of papillae, chronic atrophic candidiasis and fi ssured tongue.[20] Periodontitis Nodular lesions may be present over the anterior part of the tongue, giving a pavement-stone appearance and ultimately Periodontoclasia lead to scarring. The muscles of the tongue are usually spared Specific pulpitis unlike the extensive involvement seen in other subcutaneous Periapical granulomas muscles. The buccal mucosa may appear paler than normal. In advanced cases, there may be diffuse infi ltration, swellings, soft palate.[22] Noduloulcerative lesions over the palate may at papulonodules and ulceration. times mimic squamous cell carcinoma.[23] Further in the course of disease, the mucosa of the soft palate, uvula and fauces of Hard palate, as already mentioned, is the most common site tonsils become infi ltrated with the appearance of miliary papules of involvement and shows the most varied type of lesions. The or nodules. These may break down forming superfi cial ulcers, disease may present as erythematous or reddish papules that especially during leprosy reactions. The uvula may initially gradually increase in size and number and coalesce to form a appear swollen and later completely effaced or may become generalized nodular sub-mucosal infi ltrate [Figures 1-4]. As the adherent to the soft palate. Scarring in the region of fauces may disease progresses, the mucosa loses its shininess and gives lead to a triangular deformity instead of the normal faucial arch. a matt-like appearance.[21] Ultimately, there may be palatal ulceration and perforation leading to communication between Involvement of gums may be in the form of gingivitis, the oral and nasal cavity. At this time, patients may develop periodontitis and periodontoclasia. Gums appear swollen with functional abnormalities like diffi culty in swallowing, eating and shiny and purplish mucosa and bleed easily with decreased drinking. Bucci et al. reported erythema nodosum leprosum to sensitivity to pain. Dental involvement has been less extensively be an important but rare cause of destruction of the hard and studied. Miranda et al. described three different types of leprotic 102 Indian Dermatology Online Journal - May-August 2012 - Volume 3 - Issue 2 Pallagatti, et al.: Oral cavity and leprosy involvement of teeth: specifi c pulpitis, dental anomalies and type of leprosy.[24] In addition, it has been postulated that oral periapical granulomas. Marti et al. further concluded that chronic infections may be associated with the recurrence of leprosy patients tend to have poor dental and periodontal leprosy reaction episodes. Motta et al. compared 38 patients health, unrelated to the presence of facial destruction or the with leprosy – 19 with and 19 without oral infections – and found the latter group to show clinical improvement in leprosy reactions after dental treatment.[25] Histopathological examination of the mucosal lesions may show variable features. Scheepers et al. described epithelial atrophy to be a feature seen only in patients with lepromatous
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