This 47-year-old male presented with a non-healing tongue ulcer of 3 months’ duration and associated pain for 2 months. He had initially noticed the asymptomatic ulcer on the ventral surface of tongue which had been increasing in size for the last 1 month. He had smoked beedis for the last 20 years and had consumed alcohol daily for past 15 years. On examination, ulcers were noticed in the tongue and buccal mucosa. A solitary ulcer (3 cm × 4 cm) with undermined edges and minimal induration was seen on right ventral surface of the tongue extending from the midline past the lateral border, up to the dorsal area of the anterior two-thirds of the tongue []. The area adjacent to the tongue ulcer appeared to be lobulated. Another ulcer (0.5 cm × 0.5 cm), also with an undermined edge was seen on the dorsal surface of tongue. In the left buccal mucosa, a single ulcer (1 × 1 cm2) covered with pseudomembrane was present, extending 3 cm from the angle of the mouth and 5 mm below the occlusal plane []. The patient was not aware of this ulcer. A single firm, non-tender (<1 cm) sub-mandibular lymph node was present on the right side.\nProvisional diagnoses of squamous cell carcinoma and lichen planus were given for the lesions of the tongue and buccal mucosa, respectively. Incisional biopsy from the edge of tongue ulcer revealed proliferating epithelium with the underlying connective tissue exhibiting chronic inflammatory cell infiltrate without evidence of epithelial dysplasia or malignant invasion. Biopsy was repeated from a different area of the tongue ulcer for further review. On examining serial sections, giant cells with peripherally arranged nucleus resembling Langerhans cells were appreciated along with caseous necrosis []. Chest radiography revealed bilateral upper lobe infiltrates [], and sputum was positive for acid-fast bacilli. HIV was negative. With anti-tuberculous therapy the lesions began to heal on a follow-up visit a month later. He was referred to local primary health care center for continuation of therapy.
A 37-year-old female reported to the department of oral medicine and radiology with a chief complaint of nonpainful swelling of the upper anterior gingiva for the past 8 months. The gingiva increased gradually in size with time. The patient had a history of weakness over the past 3–4 months, loss of appetite and loss of weight of about 5 kg during the past 3 months. Her medical history revealed no systemic problems, no cough with expectoration, no known history of contact with a tuberculous patient and no history of dental trauma or any surgery in the affected area. On examination, she was of average built, pulse, temperature and respiration rates were normal. Extraoral examination revealed no cervical lymphadenopathy. Intraoral examination showed diffuse enlargement of labial maxillary gingiva (marginal and attached gingiva) and alveolar mucosa extending from tooth number 13–23. The gingiva was red, irregular, pebbled and granular in appearance with surface ulceration []. On palpation, the swelling was slightly tender, firm and had a tendency for bleeding on provocation. The rest of the OC was normal. Complete hemogram and IOPA radiograph of 11, 12, 21 and 22 were advised. Results were within normal limits, except for a marginal rise in leukocyte count and an elevated erythrocyte sedimentation rate (ESR). IOPA radiograph revealed interdental bone loss in relation to 11 and 21. The patient was then advised tuberculin test, chest X-ray and sputum culture. A tuberculin (Mantoux) test was positive, suggesting tubercular infection. Chest radiography (posteroanterior view) revealed no abnormalities []. Culture of sputum was negative for M. tuberculosis. An incisional biopsy from the maxillary labial gingiva adjacent to the central incisors was performed. Histopathological examination revealed clusters of epithelioid cells, caseating necrosis and numerous Langhans-type giant cells surrounded by a chronic inflammatory type of infiltrate [Figure and ]. In view of these findings, a working diagnosis of primary tuberculous gingival enlargement was made. The patient was later administered antitubercular regime, and within 2 months of therapy, the lesion healed spontaneously []. No recurrence was observed even after 6 months of follow-up. During this period, the patient was instructed not to undergo any surgical procedure within the OC. Further, conservative periodontal therapy, which included scaling and root planning, was carried out with minimal trauma to gingival and after consulting the physician in-charge.