A 23-year-old girl reported to the department of oral medicine and radiology with progressive, nonpainful swelling of the gingiva on the labial aspect of the upper and lower anterior teeth with 6 months' duration. There was a history of evening rise in temperature and weakness over the last 3 months. The patient also had a loss of appetite over the last 4 months and a weight loss of about 4.5 kg during the last 8 months. There were no systemic problems, no cough with expectoration and no history of dental trauma or surgery in the affected area. Extraoral examination revealed no cervical lymphadenopathy. Intraoral examination revealed diffuse enlargement of the upper and lower gingiva on the labial surface of anterior maxillary and mandibular teeth []. On palpation, the swelling was slightly tender and firm. The rest of the OC was normal except for the few deep carious teeth. Differential diagnoses were enlargement due to drugs, infection and hematologic malignancy. The possibility of drug-induced enlargement was ruled out based on medical history. The biochemical tests were within normal limits, except for a marginal rise in leukocyte count (13 × 10 9/L) and an elevated ESR of 56 mm/h (Westergren method), which ruled out leukemia-associated enlargement and raised the possibility of one of the common causes of high ESR, TB. An incisional biopsy was carried out under LA in relation to the gingiva of the mandibular right central incisor, in collaboration with the department of periodontics and implantology. Histopathological examination was carried out that revealed clusters of epithelioid cells surrounded by a chronic inflammatory type of infiltrate. There was no evidence of caseating necrosis, but numerous Langhans giant cells were visible in the clusters of epithelioid cells suggestive of a “hard tubercle” [Figure and ]. To eliminate the possibility of localized granulomatous changes superimposed on an area of gingival enlargement, incisional biopsy was repeated in the remaining three quadrants. Histopathology showed similar granulomatous changes in all tissue specimens examined. The tuberculin (Mantoux) test was positive, suggesting tubercular infection. Chest radiography (posteroanterior view) revealed no abnormalities []. A computed tomography scan of the head and neck region was also performed to determine the status of the underlying maxilla and mandible. The scan did not reveal any bone abnormalities. A culture of the sputum, obtained by forceful coughing, was negative for M. tuberculosis. Special staining of formalin-fixed, paraffin-embedded tissue specimens for Mycobacteria, i.e., Ziehl–Neelsen and auramine–rhodamine stain, was negative. An immunologic test to detect antibodies against Mycobacterium in the patient's serum (ELISA) was positive. Polymerase chain reaction (PCR) assay was also carried out using six 5-μm sections of paraffin-embedded tissue to identify specific sequences of M. tuberculosis complex, with adequate controls. The DNA was used as an amplifying target for the sequence IS-6110, which is specific for M. tuberculosis. Positive PCR results confirmed the presence of M. tuberculosis in the tissue samples. In view of these findings, a final diagnosis of primary tuberculous gingival enlargement was made. In consultation with the patients' physicians, antitubercular therapy (ATT) was initiated. During this period, the patient was instructed not to undergo any ultrasonic scaling and polishing or surgical procedure within the OC and was warned about the chance of transmitting the disease to others via aerosol and salivary contamination. After completion of a 6-month regimen of basic periodontal therapy, which included scaling and root planning, oral hygiene instructions were instituted under CDC-issued guidelines. This resulted in significant regression of the enlarged gingivae in both the arches. Gingivectomy and gingivoplasty were performed to shape and contour the residual enlargement under universal aseptic conditions []. No recurrence of lesion occurred during 1-year follow-up [].
A 45-year-old female presented with a chief complaint of painful ulcer on the palate for the last 1 year, which gradually increased to the present size. She had received antibiotics (amoxicillin plus clavulanate) prescribed by local practitioners, but there was no response. She did not have any systemic complaints such as cough, fever or weight loss and had no history of any allergy. There was no cervical lymphadenopathy or any other abnormal findings. Intraoral examination revealed gingival ulcerations involving marginal and attached gingiva in relation to 11–14 and mucosa of the anterior hard palate. The ulcer is indurated, irregular, having an undermined margin and a yellowish granular necrotic base []. Owing to suspicion of a malignant lesion, an incisional biopsy was undertaken from anterior mucosa of hard palate following the baseline investigations which were within normal limits. Histopathological examination (HPE) of the surgical specimen showed a conserved epithelium covering the subepithelial layers, with widespread caseating granulomas surrounded by lymphocytes, epithelial cells and Langhans-type giant cells []. No neoplastic changes were observed. Ziehl–Neelsen staining was negative. With all these data, the diagnosis of oral TB was suggested and systemic analyses were performed to determine its primary or secondary origin. The Mantoux test showed a positive reaction. Chest X-ray did not show any lesion suggestive of pulmonary TB. Three sputum specimens were smear negative and culture negative. Although the first clinical impression raised suspicion of a malignant or traumatic process, these were both dismissed based on the pathology results. In fact, the presence of caseating granulomas surrounded by lymphocytes, epithelial cells and Langhans-type giant cells confirmed the diagnosis of TB. The patient was referred to the department of infectious diseases for further management. Treatment was started with isoniazid (300 mg/day), rifampicin (600 mg/day), pyrazinamide (1500 mg/day) and ethambutol (900 mg/day) for 2 months and the patient was asked to continue with the first two drugs for the next 4 months. No pulmonary signs and symptoms were present. The oral lesions resolved within 4 weeks of treatment []. The patient was followed for 9 months after the treatment with no recurrence of lesion.