tuberculosis of oral cavity is a rare entity . even before antitubercular chemotherapy era , oral lesions occurred less commonly in patients with pulmonary tuberculosis . a 55-year - old labourer was referred to the outpatient department of our centre as a case of suspected gingivobu - ccal carcinoma for further evaluation and management . he had a non - healing ulcer in the oral cavity for one and a half months , which was associated with pain . he had been well until six weeks earlier when he noticed a lesion in his oral cavity . he visited the local doctor for this and was given symptomatic treatment and vitamin supplements . on enquiry , he had no systemic symptoms of chronic disease like fever , weight loss , and loss of appetite or weight . he also had no history of tuberculosis or contact with a tuberculosis patient . on clinical examination , the patient had an ulcer in the right lower gingivobuccal sulcus of size about 21 cm and was covered with slough . there was also mild fullness and soft tissue induration in the cheek below the lip . the patient 's height was 167 cm ; weight , 62 kg ; blood pressure , 124/76 mm hg ; and pulse , 74 beats per minute . on further investigation , haemoglobin was 13.9 gm% , total white blood cell count was 6,400 cells / dl , and erythrocyte sedimentation rate was 13 mm at the end of one hour . these are usually accompanied by associated history like a stressor event or the presence of a sharp tooth , etc , pointing to diagnosis . . the most common cause of a non - healing ulcerative lesion in the oral cavity is malignancy . the history is usually that of a rapidly growing lesion that does not respond well to any form of management . in most cases it is also usually accompanied by weight loss and features of chronic disease . in a developing country every year , approximately 2.2 million people develop tuberculosis , of which about one million are new - smear positive highly infectious cases and about 5 lakh people die of tuberculosis every year . this should be considered in the differential diagnosis , particularly in a non - healing lesion that does not respond to the usual therapy . actinomycosis is a rare , chronic , spreading , suppurative , granulomatous and fibrosing infection characterised by the formation of multiple abscess , draining sinuses and the release of characteristic  sulphur granules  . peak incidence occurs between 15 and 30 years , and males are more frequently infected than females . the majority of examples of the clinical disease are cervicofacial ( 55% ) , with only 20% occurring in an abdo - minopelvic form and 15% as a thoracopulmonic form . . are anaerobic or aerotolerant ( facultatively anaerobic ) , non - sporulating , gram - positive bacteria that tend to form branching rods and filaments and have a fermentative type of carbohydrate metabolism . are not regarded as virulent human pathogens and are best considered as opportunistic pathogens , as they are normally present in healthy individuals as commensals of the mouth cavity and the upper respiratory tract . their presence in the oral and respiratory specimens does not necessarily signify clinical disease and might often not be reported . are polymicrobial . the copathogens are most commonly colonisers of the respective organ systems involved . they act synergistically by inhibiting host - defense mechanisms or reducing the oxygen tension in the affected tissue , which promotes the growth of actinomyces spp . syphilis is an infectious disease caused by a spirochete called treponema pallidum ( tp ) , which has a tropism for several organs and tissues in the body , causing complex clinical manifestations . transmission of syphilis occurs mostly through sexual intercourse and sites of inoculations are usually genitals , though it can also be extragenital . it is characterised by several different dermatological lesions , involving both skin and mucous membrane . in the first stage of the disease ( primary syphilis ) , oral chancres syphilitic chancre is a solitary , painless , indurated , hard in consistency , reddish ulcer , accompanied by regional lymphadenopathy , which is localised at the site of tp inoculation and usually resolves after approximately one month without scarring . in secondary syphilis , the oral manifestations are characteristic lesions , which are multiple mucous patches that are slightly raised and covered by grayish , white pseudomembranes and surrounded by erythema . oral lesions are often painful and snail track ulcers result when multiple mucous patches become confluent . the diagnosis is confirmed by the specific serology and the demonstration of tp in the lesion . tp has a slender , coiled morphology and when examined by dark - field microscopy , it was seen moving in a drifting rotary motion ( corkscrew ) . naat is better than dark - field microscopic examination in the case of oral lesions because of the possible presence of saprophytic tp in the mouth . chest x - ray revealed an ill - defined patchy opacity and reticulo - nodular opacities in the upper and mid zone of both lungs [ figure 2 ] . sputum was positive for the presence of acid - fast bacilli 1 + in two consecutive samples . these are usually accompanied by associated history like a stressor event or the presence of a sharp tooth , etc , pointing to diagnosis . . the most common cause of a non - healing ulcerative lesion in the oral cavity is malignancy . the history is usually that of a rapidly growing lesion that does not respond well to any form of management . in most cases it is also usually accompanied by weight loss and features of chronic disease . in a developing country every year , approximately 2.2 million people develop tuberculosis , of which about one million are new - smear positive highly infectious cases and about 5 lakh people die of tuberculosis every year . this should be considered in the differential diagnosis , particularly in a non - healing lesion that does not respond to the usual therapy . actinomycosis is a rare , chronic , spreading , suppurative , granulomatous and fibrosing infection characterised by the formation of multiple abscess , draining sinuses and the release of characteristic  sulphur granules  . peak incidence occurs between 15 and 30 years , and males are more frequently infected than females . the majority of examples of the clinical disease are cervicofacial ( 55% ) , with only 20% occurring in an abdo - minopelvic form and 15% as a thoracopulmonic form . are anaerobic or aerotolerant ( facultatively anaerobic ) , non - sporulating , gram - positive bacteria that tend to form branching rods and filaments and have a fermentative type of carbohydrate metabolism . are not regarded as virulent human pathogens and are best considered as opportunistic pathogens , as they are normally present in healthy individuals as commensals of the mouth cavity and the upper respiratory tract . their presence in the oral and respiratory specimens does not necessarily signify clinical disease and might often not be reported . they act synergistically by inhibiting host - defense mechanisms or reducing the oxygen tension in the affected tissue , which promotes the growth of actinomyces spp . syphilis is an infectious disease caused by a spirochete called treponema pallidum ( tp ) , which has a tropism for several organs and tissues in the body , causing complex clinical manifestations . transmission of syphilis occurs mostly through sexual intercourse and sites of inoculations are usually genitals , though it can also be extragenital . it is characterised by several different dermatological lesions , involving both skin and mucous membrane . in the first stage of the disease ( primary syphilis ) , oral chancres syphilitic chancre is a solitary , painless , indurated , hard in consistency , reddish ulcer , accompanied by regional lymphadenopathy , which is localised at the site of tp inoculation and usually resolves after approximately one month without scarring . in secondary syphilis , the oral manifestations are characteristic lesions , which are multiple mucous patches that are slightly raised and covered by grayish , white pseudomembranes and surrounded by erythema . oral lesions are often painful and snail track ulcers result when multiple mucous patches become confluent . the diagnosis is confirmed by the specific serology and the demonstration of tp in the lesion . tp has a slender , coiled morphology and when examined by dark - field microscopy , it was seen moving in a drifting rotary motion ( corkscrew ) . naat is better than dark - field microscopic examination in the case of oral lesions because of the possible presence of saprophytic tp in the mouth . chest x - ray revealed an ill - defined patchy opacity and reticulo - nodular opacities in the upper and mid zone of both lungs [ figure 2 ] . sputum was positive for the presence of acid - fast bacilli 1 + in two consecutive samples . primary tuberculosis of the oral cavity is rare , as it occurs in young individuals and is associated with cervical lymphadenopathy.[258 ] secondary tuberculosis of the oral cavity usually occurs following pulmonary tuberculosis . it is more common than the primary variety and occurs more often in old age.[257 ] tuberculosis of the oral cavity is rare because the intact mucosa is resistant to tuberculous infection and saliva has a protective effect . other possible causes for the relative rarity of oral tuberculosis include the presence of saprophytes in the oral cavity and resistance of stratified muscles to bacterial invasion . there are reports in which dentists with pulmonary tuberculosis have infected patients during dental manipulation . nasolabial infection occurred in a physician who administered mouth - to - mouth resuscitation to a tuberculosis patient . other sites include the gingiva , soft palate , lip , buccal mucosa , floor of the mouth , and gingivobuccal sulcus . oral tuberculosis may present as single or multiple , painful or painless ulcers with irregular border . it can also present as nodules , fissures , vesicles , or peri - apical granulomas . the oral tuberculous ulcers have some characteristic clinical features including chronicity , hyperemic changes , and multiple or satellite lesions , which lead to the suspicion of a tuberculous lesion . oral tuberculosis occurs in 0.4 - 1.5% of patients with pulmonary tuberculosis . at present , with improved community health and anti - tubercular medication , the incidence of tuberculosis has decreased . oral tuberculosis is not considered in the differential diagnosis of patients with oral ulcer by many clinicians ; hence , it is missed or the treatment is delayed . the purpose of this paper is to alert clinicians to consider oral tuberculosis in patients with non - healing oral ulcer . on consultation with the physician , anti - tubercular therapy was initiated with isoniazid ( 10 mg / kg of body weight ) , rifampicin ( 10 - 20 mg / kg of body weight ) , and pyrazinamide ( 10 - 20 mg / kg of body weight ) and ethambutol for two months , followed by isoniazid and rifampicin for the following four months . during the period , the patient was instructed not to undergo any surgical procedure within the oral cavity and was warned of transmitting the disease to others . tuberculous ulcer of the oral cavity secondary to pulmonary tuberculosis . from the department of head and neck oncology , tata memorial hospital , mumbai .
tuberculosis of the oral cavity is a rare condition . 
 a 55-year - old labourer was referred as a case of oral cancer for further management . 
 the patient had no systemic symptoms . 
 biopsy of the lesion revealed caseating granulomatous inflammation . 
 chest x - ray and sputum revealed evidence of asymptomatic pulmonary tuberculosis . 
 the purpose of this paper is to sensitize clinicians to consider oral tuberculosis as a differential diagnosis in patients with an non - healing oral cavity ulcer .