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.
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.