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 49-year-old male was referred to our department with the complaint of painful and non-healing ulcer of the tongue for 4 months. There was no history of fever, night sweats, cough, decreased appetite and weight loss. He did not give any history of traumatic episode preceding the development of tongue ulcer. He denied any history of similar lesions in the past. He is an occasional smoker. The rest of his medical and surgical history was unremarkable. His dental history was not significant. There was no history of TB in his family members. He was repeatedly treated in a government hospital with topical antiseptics and oral antibiotics (ampicillin plus cloxacillin and metronidazole) and analgesics, but the lesion did not subside so he was referred to our hospital for the further management. On general examination, he was of average built. Intraoral examination revealed an indurated ulcer measuring 1.5 cm × 1.0 cm on the left dorsolateral border of anterior part of tongue. It was tender on palpation with irregular borders and did not bleed on touch. The remaining part of the tongue appeared normal in texture and color. Mobility of the tongue was normal. He had poor oral hygiene along with sharp tooth in relation to 34. There were no palpable cervical lymph nodes. Provisional diagnosis of chronic traumatic ulcer was made as the possibility of ulcer due to repeated trauma by the sharp tooth. Chest X-ray did not reveal any evidence of active lesion. Sputum for AFB was negative on Ziehl–Neelsen stain. Complete blood count was within normal limit. His ESR value was 20 mm/hr. Serum biochemistry and renal function tests were within normal limits. Serological investigation for human immune deficiency virus (HIV) was negative. Coronoplasty of adjacent sharp cusps was done, and since the ulcer presented for more than 2 months, an incisional biopsy was taken under local anesthesia containing an ulcerated lesion along with the normal looking margin and the specimen was sent for HPE. Microscopically, the lesion revealed the stratified squamous epithelium with granulomatous inflammation containing Langhans-type giant cells, epithelioid cells and foci of caseous necrosis, strongly suggestive of TB. The patient was then started on ATT. The ulcer gradually started fading once drug therapy was started (ATT) and the tuberculous ulcer healed completely by the 2 months of ATT containing isoniazid, rifampicin, pyrazinamide and ethambutol. The patient was advised to continue ATT containing isoniazid and rifampicin for another 4 months. At the end of total 6 month's ATT course, there was no evidence of ulcer at the primary site.