Oral lesions in leprosy.

Abstract

Leprotic oral lesions are more common in the lepromatous form of leprosy, indicate a late manifestation, and have a great epidemiological importance as a source of infection.
Patients with leprosy were examined searching for oral lesions. Biopsies of the left buccal mucosa in all patients, and of oral lesions, were performed and were stained with H & E and Wade.
Oral lesions were found in 26 patients, 11 lepromatous leprosy, 14 borderline leprosy, and one tuberculoid leprosy. Clinically 5 patients had enanthem of the anterior pillars, 3 of the uvula and 3 of the palate. Two had palatal infiltration. Viable bacilli were found in two lepromatous patients. Biopsies of the buccal mucosa showed no change or a nonspecific inflammatory infiltrate. Oral clinical alterations were present in 69% of the patients; of these 50% showed histopathological features in an area without any lesion.
Our clinical and histopathological findings corroborate earlier reports that there is a reduced incidence of oral changes, which is probably due to early treatment. The maintenance of oral infection in this area can also lead to and maintain lepra reactions, while they may also act as possible infection sources. Attention should be given to oral disease in leprosy because detection and treatment of oral lesions can prevent the spread of the disease.

Full text

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CMYK381
Study
Oral lesions in leprosyOral lesions in leprosy
Oral lesions in leprosyOral lesions in leprosy
Oral lesions in leprosy
Ana Paula Fucci da Costa, José Augusto da Costa Nery, Maria Leide Wan-del-Rey de Oliveira,Ana Paula Fucci da Costa, José Augusto da Costa Nery, Maria Leide Wan-del-Rey de Oliveira,
Ana Paula Fucci da Costa, José Augusto da Costa Nery, Maria Leide Wan-del-Rey de Oliveira,Ana Paula Fucci da Costa, José Augusto da Costa Nery, Maria Leide Wan-del-Rey de Oliveira,
Ana Paula Fucci da Costa, José Augusto da Costa Nery, Maria Leide Wan-del-Rey de Oliveira,
Tullia Cuzzi,* Marcia Ramos-e-SilvaTullia Cuzzi,* Marcia Ramos-e-Silva
Tullia Cuzzi,* Marcia Ramos-e-SilvaTullia Cuzzi,* Marcia Ramos-e-Silva
Tullia Cuzzi,* Marcia Ramos-e-Silva
Departments of Dermatology & *Pathology, HUCFF-UFRJ and School of Medicine, Federal University of Rio de Janeiro, Brazil.
Address for correspondence: Marcia Ramos-e-Silva, Rua Sorocaba 464/205, 22271-110, Rio de Janeiro, Brazil.
E-mail: ramos.e.silva@dermato.med.br
ABSTRACT
Background: Leprotic oral lesions are more common in the lepromatous form of leprosy, indicate a late manifestation,
and have a great epidemiological importance as a source of infection. Methods: Patients with leprosy were examined
searching for oral lesions. Biopsies of the left buccal mucosa in all patients, and of oral lesions, were performed and
were stained with H&E and Wade. Results: Oral lesions were found in 26 patients, 11 lepromatous leprosy, 14 borderline
leprosy, and one tuberculoid leprosy. Clinically 5 patients had enanthem of the anterior pillars, 3 of the uvula and 3 of
the palate. Two had palatal infiltration. Viable bacilli were found in two lepromatous patients. Biopsies of the buccal
mucosa showed no change or a nonspecific inflammatory infiltrate. Oral clinical alterations were present in 69% of the
patients; of these 50% showed histopathological features in an area without any lesion. Discussion: Our clinical and
histopathological findings corroborate earlier reports that there is a reduced incidence of oral changes, which is probably
due to early treatment. The maintenance of oral infection in this area can also lead to and maintain lepra reactions,
while they may also act as possible infection sources. Attention should be given to oral disease in leprosy because
detection and treatment of oral lesions can prevent the spread of the disease.
KEY WORDS: Leprosy, Mouth, Buccal mucosa, Oral manifestations
How to cite this article: Fucci da Costa AP, Augusto da Costa Nery J, Wan-del-Rey de Oliveira ML, Cuzzi T, Ramos-e-Silva M. Oral lesions in
leprosy. Indian J Dermatol Venereol Leprol 2003;69:381-5.
Paper Received: November, 2003. Paper Accepted: December, 2003. Source of Support: Nil.
INTRODUCTION
Leprosy is still endemic in Brazil which has the second
highest number of cases in the world.1 Oral and nasal
lesions of leprosy are probably sources of spread of
bacilli and transmission of the disease.
These lesions are common in the lepromatous form,2-5
with the prevalence reported to range from 19% to 60%
of the patients.3,6,7 The presence of oral lesions is
directly proportional to the duration of the disease,8
indicating that these are a late manifestation.2,5,9-11
METHODS
An investigation was performed in HUCFF-UFRJ (Brazil)
with the objective of studying the oral lesions in leprosy,
especially in patients with the borderline and
lepromatous forms. All patients with either of these
clinical forms who had never taken treatment or who
had received not more than one dose of MDT-MB
(WHO), and who came for consultation at the Leprosy
Out-Patient Clinics for one year, were screened for oral
lesions. Oral lesions were biopsied and in their absence
biopsies were taken of the left buccal mucosa. The

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Figure 3:Histopathology of oral leprotic lesion – absence of
grenz zone separating the epidermis and the infiltrate
(200x HE)
Figure 4:Histopathology of oral lepromatous lesion – same
patient of figure 1 – note the greater number of BAAR
(400xWade)
Figure 1:Lepromatous leprosy – whitish lesions on the palate
Fucci da Costa AP , et al: Oral lesions in leprosy
biopsies were taken with a 3 mm punch, after local
anesthesia, and were stained with hematoxylin-eosin
(H&E) and Wade (AFB) stain.
RESULTS
The study included 26 patients 18 male and 8 female
with leprosy whose oral lesions were evaluated and
biopsied. The ages varied from 16 to 71 years. Eleven
had the lepromatous form, 14 borderline, and one
tuberculoid. The clinical findings are summarized in
Table 1 (Figures 1 and 2). In two lepromatous patients
solid staining bacilli were found on histopathological
examination. Biopsies of the buccal mucosa did not
show any changes or presented a nonspecific
inflammatory infiltrate, without bacilli, even in patients
with lesions on the hard palate. The histopathological
findings of the buccal mucosa and of the oral lesions
are listed in Tables 2 and 3 (Figures 3 and 4).
Table 1: Clinical findings
N%
Enanthem of the anterior pillars
Enanthem of the uvula
Enanthem of the palate
Enanthem of the buccal mucosa
Ulceration of the buccal mucosa
Ulceration of the hard palate
Infiltration of the palate
Nodules in the palate
Total
Absence of lesions
5
3
3
2
1*
1*
2*
1*
18
12
69.23
46.15
(*Four patients had two types of lesions)
Figure 2:Lepromatous leprosy – enanthem of the anterior pillar

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DISCUSSION
The oral lesions in leprosy develop insidiously, are
generally asymptomatic and are secondary to nasal
changes.8,12 The most frequently affected site is the hard
palate.12,15,18,20 The greater prevalence in men could be
explained by the fact that women seek doctor’s advice
earlier, perhaps for esthetical reasons.5
M. leprae favors temperatures a little below the body
temperature for its multiplication,13,14 Based on this fact,
a pathophysiologic mechanism is postulated for oral
involvement: a nasal lesion with obstruction of the air
flow leads to oral breathing (mouth breathing), which
is very common in lepromatous leprosy. This causes a
decrease in the intra-oral temperature, mainly in sites
near the air intake, the anterior areas, facilitating the
harboring of the bacillus.11,13,14
The sequence of pathological alterations would follow
the same pattern described by Pinkerton in 1932 in
the nasal and oral mucous membranes: congestion,
infiltration, and formation of nodules, possible
ulceration, atrophies and fibrosis.3,8,15 Important
medical and odontologic complications may follow the
involvement of the oral and nasal mucous membrane
and the bones of the face in leprosy.16
In the advanced stages, there may be deformities and
functional alterations, such as fibrosis and retraction
of the soft palate or perforation of the hard palate,
with serious disturbances in phonation, and nasal
regurgitation of food.8 Scheepers and Lemmer
postulate that erythema nodosum leprosum (or
reaction type II) is an important cause for destruction,
perforation and deformation of the palate and uvula,
alerting one to the need for more effective treatment
of that condition.17
Some authors have emphasized the epidemiological
importance of oral lesions as an infection source,5 since
viable bacilli have been detected in these lesions by
histopathological exam through smears and by rinsing
of the oral cavity.8 For others, the prevalence is of
granulous bacilli.9
Morphologically the lesions vary from enanthemas to
ulcers, perforations and scars, passing through papules,
nodules (lepromas) and superficial erosions. They can
involve the following areas:
1. Palate: Although most authors have found more
serious changes in the mid-forward portions, some
have found the soft palate to be more commonly
affected area.2,19 The most varied types of lesions
are observed: infiltration, ulceration, perforation,
and reddish or yellow-reddish nodules, sessile or
pedunculated, varying from 2 to 10 mm, some
confluent, and prone to ulceration.3,10
2. Tongue: It is affected in 17% to 25% of the cases,4,11
mainly the dorsal surface, especially the anterior
two-thirds.3,8 Changes from superficial erosions
with loss of the papillae and longitudinal fissures
have been described8 to nodular infiltration,2 that
could lead to a “paving stone appearance”.8,10
Scarring can also occur. Unlike other subcutaneous
muscles, in which a great number of bacilli are
observed, the muscles of the tongue do not exhibit
significant numbers. Mukjerhee11 and Bucci et al.19
suggest that the lesions of the base of the tongue
could originate from highly infectious nasal
secretions, which pass from the nasal to the oral
cavity.
3. Uvula: In extreme cases there is intense fibrosis with
partial loss or even complete destruction of the
Fucci da Costa AP , et al: Oral lesions in leprosy
Table 2: Histopathological findings in buccal mucosa
N%
(H&E)
Absence of alterations
Nonspecific inflammatory infiltrate
Vascular congestion and ectasia
(WADE)
+ (positive)
– (negative)
16
10
3
61.53
50
0
26
0
100
Table 3: Histopathological findings in oral lesions (H&E)
N
(H&E)
Absence of changes
Nonspecific inflammatory infiltrate
Vascular congestion and ectasia
Inflammatory infiltrate presenting xanthomas
(WADE)
+ (positive)
– (negative)
0
3
3
2
2
3

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uvula.3,10
4. Lips: There may be macrocheilia (caused by
infiltration) or microstomia (caused by ulceration
and subsequent repair with fibrosis of perioral or
lip lepromas).3,10
5. Gums: They are usually affected in the area behind
the upper central incisors, often by contiguity, of
lesions of the hard palate.8 Chronic gingivitis,
periodontitis and periodontoclasia may occur.20
Finally, osteodental changes have also been described.
Interest in these changes was raised by Møller-
Christensen, a Danish archeologist, who, in 1952, when
examining a cemetery of lepers of the Middle Age,
verified typical bone alterations of certain parts of the
face: inflammatory endonasal changes, atrophy of the
forward nasal spine and of the alveolar pre-maxillary
processes, with loss of the upper central and lateral
incisors. He termed the facial changes resulting from
these changes as facies leprosy.21
Our findings are similar to those in the literature. Sixty
nine percent of the patients presented oral clinical
alterations and of those 50% showed histopathological
features in an area without lesions (Tables 1 and 2). In
the two cases in which specific lesions were found, the
hard palate was the site of involvement.5,8,13 The areas
of involvement in order of frequency, are the soft palate,
the uvula and the hard palate, tongue, gum and lips.2-
5,8,19,22-24 Both patients with oral lesions had lepromatous
leprosy, and had more numerous bacilli in the palatal
lesions than in their cutaneous biopsies, which is
unusual.25 The absence of the grenz zone in oral lesions,
as described by several authors,4,10 was observed in
these two patients, a fact that could facilitate the
dispersion of bacilli present in the lesions of the
lepromatous patients.
Histopathological changes observed in the buccal
mucosa corroborate earlier reports that there are few
changes in that region.5,8,19 Alfieri et al studied 30
patients (15 with borderline leprosy and 15 with
tuberculoid leprosy reaction) and found specific oral
lesions in 8 and 5 patients respectively.25 However,
the inflammatory infiltrate in the lesions was less,
with only a few bacilli. Only one case had ulceration.
They concluded that in those clinical forms the oral
lesions are not an important source of bacillary
elimination.
Pellegrino, Opromolla and Campos performed bacillary
studies in leprosy patients, and found numerous acid-
fast bacilli in the skin and palate, usually forming globi,
and fewer bacilli in the nasal mucosa.19 They observed
a similar behavior between the bacillary regression of
oral lesions and cutaneous lesions, because the oral
positivity persisted in the cases in which the cutaneous
lesions remained stationary or regressed slowly.
Since there are many important complications of
involvement of the oral and nasal mucosa and bones
of the face by leprosy,16 patients should be examined
carefully and informed regarding improvement of their
oral hygiene.8 The buccal mucosa may have a normal
appearance but may be involved in many cases with
lepromatous leprosy, and should be examined carefully
from the bacillary aspect, whenever one evaluates the
incidence of leprosy lesions in the oral cavity.2
Corroborating the idea of other authors,4,8,18 it is
believed that oral mucosal lesions are sources of
infection in lepromatous patients who expel great
numbers of bacilli when they spit, sneeze, cough or
speak,8,18 since viable bacilli have been found in some
of these lesions.2,11,12,19 Once released into the
environment, the bacilli could be viable for up to nine
days or even longer.26
The lesser incidence of oral lesions observed recently
compared to older reports15 could be because the
present treatment is more effective9,17 and is initiated
earlier, and probably because of improvement in oral
hygiene.10,27
The fact that we still see patients with oral lesions in
Rio de Janeiro is highlighted here. While our study
focused on oral mucosal changes in leprosy and not on
dental and gingival changes, compatible with
peridodontitis, nevertheless it is important to
remember that the maintenance of oral infection in
these structures can also lead to and maintain lepra
reactions. This is an important reason to always pay
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careful attention to oral disease in leprosy patients
under MDT. Their detection and early treatment can
avoid infection of new individuals.
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