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ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 67
| Issue : 6 | Page : 631-638 |
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| Oral and systemic manifestations in leprosy a hospital based study with literature review |
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Puneeta Vohra
From the Department of Oral Diagnosis, Medicine and Radiology, Faculty of Dental Sciences SGT University, Gurgaon, Haryana, India
| Date of Web Publication | 23-Feb-2023 |
Correspondence Address:
Puneeta Vohra
Department of Oral Diagnosis, Medicine and Radiology, Faculty of Dental Sciences SGT University, Gurgaon, Haryana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijd.IJD_322_19
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 Abstract | | |
Introduction: Leprosy is a chronic granulomatous disease of the peripheral nerve and muscle of upper respiratory tract. Consequence to the neighbouring primary site, oral lesions have been seen in 20-60% of patients with leprosy mainly lepromatous leprosy. The lepromatous nodules may be infective and may lead to the spread of disease and hence require proper diagnosis. Aim: To assess oral lesion in leprosy patients. To assess the disease and the occurrence of oral lesion according to age and gender. To detect any primary lesion in oral cavity and compare these lesions in duration to study. Material and Methods: One hundred patients with leprosy were examined and their oral manifestations were recorded. Results: It was found that 70 (70%) leprosy patients showed oral manifestations. Eighteen (25%) had chronic generalized periodontitis, 9 (12.8%) cases of oral melanosis, 7 (10%) atrophy of papillae and loss of taste sensation each, 6 (8.5%) complained of aphthous and candidiasis each, 5 (7.14%) depigmentation and 4 (5.71%) smokers palate, oral submucous fibrosis and fissured tongue. Conclusion: Our clinical findings are in conjugation with previous studies; however, as per the review of literature, this is the first study worldwide where we have examined 100 cases of leprosy which has not been documented till date. We suggest that the lesser incidence of oral lesions is observed recently compared to older reports because of more effective present treatment which is initiated earlier.
Keywords: Leprosy, mouth, oral manifestations
How to cite this article:
Vohra P. Oral and systemic manifestations in leprosy a hospital based study with literature review. Indian J Dermatol 2022;67:631-8 |
How to cite this URL:
Vohra P. Oral and systemic manifestations in leprosy a hospital based study with literature review. Indian J Dermatol [serial online] 2022 [cited 2023 Mar 23];67:631-8. Available from: https://www.e-ijd.org/text.asp?2022/67/6/631/370291 |
| Introduction | |  |
Leprosy (from the Greek word lepi, meaning scales on a fish), or Hansen's disease (HD), was first described in the ancient Indian texts from the 6th century BC, as a non-fatal, chronic infectious disease which was caused by Mycobacterium leprae, whose clinical manifestation was largely confined to the skin, the peripheral nervous system, the upper respiratory tract, the eyes, and the testis. It is a chronic disease caused by the bacteria M. leprae and Mycobacterium lepromatosis.[1],[2] The global burden of leprosy has declined dramatically, from 5.2 million cases in 1985 to 204,800 cases at the end of 2009, having a prevalent rate which is <1 per 10,000.[1] In India, after the introduction of MDT, the leprosy case load came down from 57.6 cases per 10,000 population in 1985 to less than one case per 10,000 population in 2005.[3] Leprosy is primarily a granulomatous disease of the peripheral nerves and mucosa of the upper respiratory tract (skin lesions are the primary external symptom).[1],[2] Left untreated, leprosy can be progressive, causing permanent damage to the skin, nerves, limbs and eyes. Infection with M. leprae remains endemic in many tropical countries.[2],[3] A proportion of infected individuals develop characteristic lesions (primarily on the skin and extremities) that are referred to as tuberculoid, lepromatous, and borderline or reactional, depending on the stage of the infection.
Tuberculoid leprosy appears clinically as macular lesions of the skin which are found to overlie subepidermal tuberculoid granulomas containing small numbers of acid-fast bacilli under microscope. Patients with tuberculoid leprosy give positive delayed hypersensitivity responses (referred to as Fernandez or Mitsuda reactions) to intradermal injections of extracts of the organism (lepromin test).[4],[5],[6]
The patient with lepromatous leprosy displays little evidence of immunity to the organism and develops multiple granulomatous masses (lepromas) affecting the face, nose, and ears (leonine facies) and the skin over the wrists, elbows, knees, and buttocks. Peripheral nerve tissue is also extensively involved, with both lepromatous nodules and apparently unaffected patches of skin often exhibiting hypoanaesthesia or anaesthesia. Patients with lepromatous leprosy are infectious and usually have progressive disease requiring antimycobacterial therapy. Borderline or reactional leprosy[4] represents an intermediate stage between the tuberculoid and lepromatous types. Cell-mediated immunity is considered to be the crucial defence against the disease and the magnitude of this immunity defines the extent of the disease.[2],[3] Oral mucosal lesions are seen in about 20-60% cases of lepromatous leprosy, whereas they are quite rare in the tuberculoid and the borderline forms. The lesions are proportional to the duration of the disease, indicating that these are late manifestations.[3],[4],[5] The propensity of the disease, when untreated, results in characteristic deformities and the recognition in most of the cultures, that the disease is communicable from person to person, has resulted historically in a profound social stigma [Table 8] and [Graph 8].
The literature contains few descriptions of oral lesions in cases of tuberculoid leprosy. Lepromatous nodules of the tongue, palate, lips, and pharynx are reported more frequently, as reddish yellow or brown sessile or pedunculated mucosal nodules[2] and destructive lesions of the palate and nasal bones can lead to deformities that are traditionally associated with this disease. Oral lesions have been reported in 20% to 60% of patients with Hansen's disease, the majority of these being lepromatous nodules. With the institution of appropriate and effective antimicrobial therapy, the patients can lead productive lives in the community, and deformities and other visible manifestations can largely be prevented.[16],[21],[22],[23] We emphasize here the importance of the evaluation of the oral mucosa by an oral health professional during patient care, since the oral lesions may act as a source of infection.[2],[3],[4],[5]
| Methods | | |
The present study was carried out in the Department of Oral Medicine and Radiology, K.M Shah Dental College, Piparia, Vadodara, Gujrat. The study was approved by Ethical Committee of Sumandeep Vidyapeeth, Vadodara. A total of 100 subjects suffering from leprosy were randomly selected for the study from the OPD of Dhiraj General Hospital & K M Shah Dental College and Hospital Piperia, Vadodara and Ansuya Hospital, a Governmental organizations working for leprosy patients, Vadodara. Written consent was obtained from each participant.
The personal and medical history along with the findings of Oral examination and Investigations were recorded in the proforma specially designed for this study. All the patients with either of clinical form having confirmed diagnosis taking multiple drug therapy (MDT) for leprosy according to WHO criteria were included irrespective of age and sex. Patients who were fully treated by anti-leprotic drugs or with history of any other systemic condition were not included in the study.
| Results | | |
The study population comprised of 100 leprosy patients 60 males and 40 females and age range from 10 years to 82 years with mean age of 37.40 ± 13.31. In study population of 100 infected leprosy patients, 75% patients had poor oral hygiene and periodontal status, 22% had fair oral hygiene and periodontal status, whereas 3% had good oral hygiene and periodontal status [Graph 1], [Graph 2], [Graph 3], [Graph 4] and [Table 1], [Table 1], [Table 2], [Table 3], [Table 4].
Ninety-three (93%) leprosy patients had systemic manifestations out of which 40 (43%) had loss of digits, 20 (21.5%) had fever and body ache, 12 (12.9%) had loss of sensation, 9 (9.6%) had ulceration, 6 (6.4%) had erythema, 2 (2.1%) had nasal congestion and discharge, and 1 (1.07%) each had depigmentation and increase in melanin pigmentation each [Figure 2]. Out of total 60 males, all had systemic manifestations, 10 (16.6%) cases had fever and body aches, followed by 30 (50%) cases of loss of digits, 8 (13.3%) cases of loss of sensation, 5 (8.3%) cases of ulceration, 4 (6.6%) cases of erythema, and 1 (1.6%) had nasal congestion and discharge. Out of total 40 females, 33 (82.5%) had systemic manifestations, 12 (36.3%) cases had fever and body aches, followed by 10 (30.3%) cases of loss of digits, 4 (12.1%) cases each of loss of sensation and ulceration, 2 (6%) cases of erythema and 1 (3%) case of nasal congestion and discharge [Graph 9] and [Table 9]. | Figure 2: Systemic manifestations of leprosy. Note- One patient may have more than one type of lesion
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 | Table 9: Systemic manifestations in males and females of study population
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The oral manifestations were seen in 70% of leprosy patients, 18 (25%) had chronic generalized periodontitis, 9 (12.8%) cases of oral melanosis, 7 (10%) atrophy of papillae and loss of taste sensation each, 6 (8.5%) complained of aphthous and candidiasis each, 5 (7.14%) depigmentation, and 4 (5.71) smokers palate, oral submucous fibrosis and fissured tongue [Figure 1]. Out of total 60 males, 41 (68.3%) had oral manifestations, 10 (24.3%) had chronic generalized periodontitis followed by 5 (12.1%) cases of each of atrophy of papillae, melanosis and loss of taste sensation, 3 (7.3%) cases of aphthous, 4 (9.7%) cases of candidiasis, 3 (7.3%) cases of depigmentation, 2 (4.8%) cases each of fissured tongue, oral sub-mucous fibrosis, and smokers palate. Out of total 40 females, 29 (72.5%) had oral manifestations, 8 (27.5%) had chronic generalized periodontitis followed by 3 (10.3%) cases of aphthous and 2 (6.8%) cases each of atrophy of papillae, loss of taste sensation, osmf, candidiasis, melanosis, smokers palate, depigmentation and fissured tongue [Graph 6] and [Table 6]. | Figure 1: Oral manifestations of leprosy.*CGP-Chronic generalized periodontitis. Note- One patient may have more than one type of lesion
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In a study population, out of 100 infected leprosy patients 86% patients had normal salivary flow, 11% had decreased salivary flow, whereas 3% had increased salivary flow [Graph 7] and [Table 7].
| Discussion | | |
In the present study, we have attempted to access oral manifestations in patients with leprosy. The sequence of pathological alterations follows the 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],[5],[6],[7] Important medical and odontologic complications may follow the involvement of the oral and nasal mucous membrane and the bones of the face in leprosy.[8] The upper airway is the main point of entry for the bacillus and a route for bacillary elimination in leprosy.[9],[10],[11],[13] For this reason, the control of the mucosal lesions is very important. The mucosal involvement is particularly outstanding in the nose, probably due to the preference of M. leprae for cooler sites. The oral lesions of leprosy occur more frequently in areas of the mouth which have a lower surface temperature. The oral lesions usually appear as ulcerations on the hard or soft palates as was observed in our case. The main oral cavity sites of leprosy include the gingiva in the anterior portion of the maxilla, the hard and soft palates, the uvula and the tongue. In advanced leprosy, the mouth can acquire the characteristics of a reservoir of bacilli, and it may thus act as an important risk factor for the transmission of the illness. M. leprae favours temperatures which are a little below the body temperature for its multiplication.[9],[13] Based on this fact, a pathophysiological mechanism has been postulated for the 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 and in the anterior areas, thus facilitating the harbouring of the bacillus. General aspects: The extremely wide spectrum of clinical manifestations of leprosy may be considered a reflection of different cellular responses to M. leprae. There is a relation between dominant cytokine profiles and clinical presentation of leprosy; interleukin-2 (IL-2) and interferon γ markedly dominate in tuberculoid lesions, whereas IL-4, IL-5 and IL-10 are common in the lepromatous forms of leprosy.[6],[7],[9],[11]
In our study population, 75% of patients had poor oral hygiene and periodontal status, 22% had fair oral hygiene and periodontal status, whereas 3% had good oral hygiene and periodontal status. These results were consistent with previous findings by Costa et al. in 2003[7] who had also insisted the maintenance of good oral hygiene to prevent further spread of infection and incidence of oral lesions.
Out of total 100 patients with leprosy, it was found that 70 (70%) had oral manifestations. The oral lesions in leprosy develop insidiously, are generally asymptomatic and are secondary to nasal changes.[9],[13]
Eighteen (25%) had chronic generalized periodontitis, 9 (12.8%) cases of oral melanosis, 7 (10%) atrophy of papillae and loss of taste sensation each, 6 (8.5%) complained of aphthous and candidiasis each, 5 (7.14%) depigmentation, 4 (5.71%) smokers palate, oral submucous fibrosis and fissured tongue; these results were in conjugation with the previous study done by Costa et al. in 2003.[7] Out of total 60 males, 41 (68.3%) had oral manifestations, 10 (24.3%) had chronic generalized periodontitis followed by 5 (12.1%) cases of each of atrophy of papillae, melanosis and loss of taste sensation, 3 (7.3%) cases of aphthous, 4 (9.7%) cases of candidiasis, 3 (7.3%) cases of depigmentation, and 2 (4.8%) cases each of fissured tongue, oral sub mucous fibrosis and smokers palate. Out of total 40 females, 29 (72.5%) had oral manifestations, 8 (27.5%) had chronic generalized periodontitis followed by 3 (10.3%) cases of aphthous, and 2 (6.8%) cases each of atrophy of papillae, loss of taste sensation, OSMF, candidiasis, melanosis, smokers palate, depigmentation and fissured tongue. Similar results were found by the previous study done by Costa et al. in 2003,[7] Martins et al.[14] in 2007 and Rawlani et al.[15] in 2008.
The most common oral manifestation in both genders was chronic generalized periodontitis; these findings could not be correlated with any other study done by various authors in past although a higher prevalence of oral manifestations in males then females was found like previous studies done by Girdhar et al. in 1979.[6] The greater prevalence in men could be explained by the fact that women seek doctor's advice earlier, perhaps for aesthetic reasons.[5],[14]
In a study population of 100 patients with leprosy, 86% patients had normal salivary flow, 11% had decreased salivary flow, whereas 3% had increased salivary flow which has not been estimated in any of the previous studies.
Out of 100 patients with leprosy, 93 (93%) had systemic manifestations out of which 40 (43%) had loss of digits, 20 (21.5%) had fever and body ache, 12 (12.9%) had loss of sensation, 9 (9.6%) had ulceration of digits, 6 (6.4%) had generalized erythema and eczema, 2 (2.1%) had nasal congestion and discharge and 1 (1.07%) each had depigmentation and increase in melanin pigmentation each. These figures are almost similar to earlier studies and reports published by various authors Girdhar et al. in 1979,[6] Bucci et al. in 1987,[5] Sheepers et al. in 1993[13] and Martinez et al. in 2007.[5],[7],[13],[14] Out of total 60 males, all had systemic manifestations, 10 (16.6%) cases had fever and body aches, followed by 30 (50%) cases of loss of digits, 8 (13.3%) cases of loss of sensation, 5 (8.3%) cases of ulceration of digits, 4 (6.6%) cases of generalized erythema and eczema, and 1 (1.6%) had nasal congestion and discharge. Out of total 40 females, 33 (82.5%) had systemic manifestations, 12 (36.3%) cases had fever and body aches, followed by 10 (30.3%) cases of loss of digits, 4 (12.1%) cases each of loss of sensation and ulceration of digits, 2 (6%) cases of generalized erythema, eczema and 1 (3%) case of nasal congestion and discharge.
The most common systemic manifestation in both genders was fever and body aches which could not be correlated with any other reports given by various authors in their previous studies.
Since there are many important complications of involvement of the oral and nasal mucosa and bones of the face by leprosy, patients should be examined carefully and informed[12] regarding improvement of their oral hygiene.[17],[18],[19] With the idea of other authors, it is believed that oral mucosal lesions are sources of infection in patients with leprosy who expel great numbers of bacilli when they spit, sneeze, cough or speak, once released into the environment, the bacilli could be viable for up to 9 days or even longer.[6],[7],[9],[10] The lesser incidence of oral lesions observed recently compared to older report could be because the present treatment is more effective and is initiated earlier, and probably because of improvement in oral hygiene.[11] To conclude, the oral cavity must be examined in cases where leprosy is suspected. With the institution of appropriate and effective antimicrobial therapy, the patients can lead productive lives in the community, and deformities and other visible manifestations can largely be prevented. Three major strategic components of leprosy control include early detection of the disease, adequate treatment and comprehensive care for prevention of disabilities and rehabilitation.[1],[17],[18],[20] Oral leprosy lesions are nonspecific in their presentation and are often over-looked by clinicians or misdiagnosed. The role of dental profession and especially the Oral Medicine specialist is of great importance in early diagnosis of oral lesions. A thorough knowledge of this chronic infection is hence necessary to provide optimum level of health care.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Ethical approval
Taken from institutional ethical committee
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9] |
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