tuberculosis is a chronic granulomatous systemic infectious disease prevalent worldwide , which can affect any part of the body , including the oral cavity . it is usually caused by inhalation of infected airborne droplets containing the m. tuberculosis bacillus , which is an aerobic , slender , non - motile , non - encapsulated , non - sporing , rod - shaped organism , ranging from 2 to 5 m . oral manifestations in tuberculosis occur in 3% of the cases involving long - standing pulmonary or systemic infection . oral lesions may present as ulcers , erythematous patches , indurated lesions , nodules or as bony jaw lesions . bony tuberculosis of the jaw is an uncommon form of extrapulmonary tuberculosis and is very rare . tuberculosis of the jaw is more common in children below the age of 18 years . primary lesions develop when the tuberculosis bacilli are directly inoculated into the oral tissues of a person who has not acquired immunity to the disease . secondary infection of the oral tissues can result from either a hematogenous or lymphatic spread . the involvement of the maxilla by tuberculous infection is the rarest of rare , although tuberculous osteomyelitis of the mandible has been reported and is more common than that in the maxilla , as it contains a lesser amount cancellous bone . hence , we document a case of tuberculous osteomyelitis of the maxilla in a 19-year - old female , who was initially suspected for multiple periodontal abscesses , which later proved to be tubercular osteomyelitis of the maxilla . a 19-year - old female patient reported to the department with a complaint of mobile teeth along with a history of pus discharge since three months . the history revealed that the patient had a painful swelling in the upper front region of the face three months back , which later subsided due to formation of multiple draining sinuses . the medical history revealed that the patient had generalized weakness , weight loss , and episodic fever for the last one month . on general examination , a diffuse swelling was present in the middle third of the upper left and right side of the face , which extended from the right to the left mid pupillary line mediolaterally and from the ala tragus line , 4 cm inferior to the infraorbital margin . superoinferiorly the swelling was slightly tender on palpation [ figure 1 ] . on intraoral examination , multiple draining sinuses were present with reference to the 23 , 26 and 14 , 15 extraction socket region ; there was discharge of pus from all the sinuses and from the extraction socket [ figures 2 - 4 ] . on digital palpation ( using index finger and thumb ) a very unusual finding was found , the maxillary teeth and maxillary arch in their entirety were movable , like a paper - thin bone [ video 1 ] . there was no carious tooth associated with the sinuses , so on the basis of the above - mentioned history and clinical presentation a provisional diagnosis of multiple periodontal abscesses was made . routine hematological , radiological , and histopathogical investigations were carried out . on the hematological investigation , the erythrocyte sedimentation rate ( esr ) was seen to be very high , which indicated a deep - seated infection . on a panoramic examination , diffuse bone loss in the maxilla , involving all the maxillary teeth , was seen [ figure 5 ] . a sputum examination for acid a chest x - ray showed that the bronchovascular markings were accentuated and in the left upper zone pulmonary koch 's was found [ figure 6 ] . a montoux test was advised , which came positive ( > 10 mm ) . a cytological smear taken from the sinus drainage fine needle aspiration cytology ( fnac ) showed no granulomatous lesion . a serological examination for m. tuberculosis antibody finally , an incisional biopsy , which is considered the gold standard , was performed in the extraction socket 14 , 15 region [ figure 7 ] . it showed granulomas of varying sizes and shapes , consisting of central langhan 's giant cells , epitheloid cells , surrounded by lymphocytes , and few plasma cells [ figure 8 ] . the above - mentioned features are consistent with a tuberculous granuloma , a chronic granulomatous lesion . therefore , a final diagnosis of pulmonary tuberculosis as a primary lesion , with a secondary lesion in the maxilla , was made . the standard anti - tubercular therapy for bone tuberculosis was started . at the four - week follow up , a marked improvement in the overall health was noticed , with an overall reduction in the mobility of the maxillary bone and teeth [ figure 9 and video 2 ] . profile picture of the patient intraoral view showing multiple draining sinuses intraoral sinuses with reference to the 23 , 25 region draining sinuses with reference to the 14 , 15 extraction socket panoramic x - ray showing diffuse bone loss in the maxilla chest x - ray shows bronchovascular markings are accentuated , with left upper zone pulmonary koch 's photomicrograph showing multinucleated giant cells incisional biopsy done with reference to the 15 region post - treatment picture showing complete healing of the sinuses in spite of the dramatic improvement in public health , tuberculosis still remains a dreaded disease in today 's world . a majority of the cases belong to the developing countries , with the highest incidence in the indian and african subcontinent . primary oral tuberculosis is rare because of various barriers present in the oral cavity , such as , intact oral mucosa , salivary enzymes , tissue antibodies , and oral saprophytes . the radiographic appearance of tb of the jaws or alveolar bone is similar to that caused by other pyogenic organisms . it usually appears as a blurring of the trabecular pattern , with irregular areas of radiolucency . generally the diagnosis of tuberculosis has been made on the basis of clinical findings and radiographs , along with sputum examination showing afb bacilli . in recent times , more advanced investigations like a dna probe and polymerase chain reaction assays allow a more sensitive and rapid diagnosis . the smears and culture for afb from the oral lesions and the sputum have been negative in our case , which can be due to many reasons . high immunity of the patient , small numbers of tubercle bacilli in the oral lesion or a previous history of prolonged antibiotic consumption . in our case , the very rarest of rare finding was noticed , the entire maxillary arch was moving like a paper - thin bone and drastic reduction was seen in the mobility after initiating anti - tuberculosis treatment . it can present in an unusual form in the oral cavity and can be misdiagnosed . with the recent reversal in the incidence of tuberculosis ; it must always be included in the differential diagnosis . concurrent pulmonary lesions should also alert the oral physician to locate a primary site of the disease in the body , before diagnosis of oral tuberculosis is considered .
tuberculosis is a chronic granulomatous systemic infectious disease caused by mycobacterium tuberculosis . 
 the oral lesions found in tuberculosis are relatively rare and may present as ulcers , erythematous patches , indurated lesions , nodules or as bony jaw lesions . 
 oral tubercular lesions sometimes present a confusing clinical presentation and can be overlooked . 
 hence , we document a case of tuberculous osteomyelitis of the maxilla in a 19-year - old female patient , who was initially treated for multiple periodontal dental abscesses , which later proved to be tubercular osteomyelitis of the maxilla . 
 although it is a rare occurrence , the differential diagnosis of tuberculous osteomyelitis must always be considered when it fails to respond to routine therapy .