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 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.