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.
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.