Tuberculous gingival enlargement: A rare clinical manifestation.

Tuberculosis (TB) is an inflammatory granulomatous disease that rarely presents as primary lesion in gingiva. Gingival involvement has been reported in only a very limited number of cases. A 13-year-old boy presented with gingival enlargement in the maxillary and mandibular anterior region associated with enlargement of lower lip with no systemic manifestations. He had a history of tuberculous lymphadenitis before 5 years which was inadequately treated. The patient's erythrocyte sedimentation rate was 70 mm/h. Histopathological report of the gingival lesion revealed noncaseating granulomas with nests of epithelioid cells and multinucleated Langhans giant cells. The patient was then referred to a physician for management, who initiated active antitubercular treatment following which the condition resolved. The aim of this article is to emphasize the importance of early diagnosis of primary TB of the gingiva which may be misdiagnosed when oral lesions are not associated with any apparent systemic infection.

INTRODUCTION

Tuberculosis (TB) is a chronic granulomatous infectious disease caused by Mycobacterium tuberculosis. Although the incidence of disease is continuously decreasing, TB remains a major health problem, especially in developing countries. Our country accounts for 15% of the world's TB patients.[1] Oral TB lesions are mostly secondary to pulmonary disease. Primary oral TB lesions generally occur in young adults. In such cases, the tongue is commonly affected followed by gingiva.[1] Reports of primary oral TB are few.[12345678] Scarcity of case reports regarding primary oral TB lesions makes it worthy of documentation.

The purpose of this article is to emphasize the importance of early diagnosis of primary TB of the oral cavity, particularly gingiva which may be misdiagnosed when oral lesions are not associated with any apparent systemic infection.

CASE HISTORY

On December 26, 2015, a 13-year-old boy visited our dental college with a chief complaint of malaligned teeth. The patient had swollen gums in the upper and lower front tooth region along with swelling and ulceration of the lower lip for the past 1 month. The swellings of lip and gums were asymptomatic [Figure 1a and b]. He had been referred to the department of periodontics from the department of orthodontics to treat the enlargement before orthodontic therapy. The patient was physically healthy. His past medical history revealed that he had undergone surgical removal of tuberculous glandular lymphadenitis in the right cervical region 5 years back. He also gave a history of being treated with rifampicin. No other antitubercular drugs were prescribed which could explain the relapse.

Figure 1

(a) Gingival enlargement in both upper and lower labial gingiva; (b) enlargement of lower lip

Clinically, the gingival enlargement had both inflammatory and fibrotic components. Based on the clinical appearance, provisional diagnosis of chronic inflammatory gingival enlargement was made. A complete hemogram was performed. All parameters except erythrocyte sedimentation rate (ESR) were normal. The ESR showed an elevated value of 70 mm/h, suggestive of underlying chronic inflammatory disease. Scaling and subgingival curettage was performed in sites with involvement [Figure 2], followed by gingivectomy and biopsy after 1 week to confirm the cause of gingival enlargement [Figures 3 and 4].

Figure 2

One week after scaling and root planing

Figure 3

Intraoperative gingivectomy in upper labial gingiva

Figure 4

Intraoperative gingivectomy in lower labial gingiva

Histopathological examination revealed multiple noncaseating granulomas, with nests of epithelioid cells and multinucleated Langhans giant cells which gave an impression suggestive of tuberculous granuloma [Figures 5 and 6]. Mycobacterium tuberculosis-Tissue polymerase chain reaction (MT-Tissue PCR) was performed and found to be negative. Serum calcium and angiotensin-converting enzyme levels were also normal ruling out sarcoidosis. The patient was reviewed postoperatively after 10 days [Figure 7] and was referred to a pulmonologist for a definitive diagnosis as well as to treat the systemic cause of gingival enlargement. As MT-Tissue PCR and chest radiographs were negative, based on the previous history of TB, ESR count of 70 mm/h, and the histopathological report, the physician diagnosed the lesion as primary tuberculous granuloma with no systemic involvement and treated the patient with antitubercular drugs for 6 months (rifampicin 450 mg, ethambutol 800 mg, isoniazid 300 mg, pyrazinamide 1 g, once daily and streptomycin injection 500 mg intramuscular, 3 times a week for the first 3 months). Six months following the treatment, the patient reported back to us. On examination, we found that the enlargement of both the gingiva and lower lip had subsided and appeared normal [Figures 8 and 9].

Figure 5

Histopathological examination showing multinucleated Langhans giant cell

Figure 6

Histopathological examination showing multiple noncaseating granulomas

Figure 7

Postoperative after 10 days

Figure 8

Postoperative 6 months after antitubercular drug therapy

Figure 9

Postoperative after 6 months showing reduction in size of swelling of lip

DISCUSSION

Our country accounts for 15% of the world's TB patients.[1] Mainly M. tuberculosis and less frequently Mycobacterium bovis cause gingival TB. It is usually associated with TB of the oropharynx, lungs, lymph nodes, and miliary TB. Cases of gingival TB associated with candidiasis, HIV infection, pulmonary TB, or cervical lymphadenopathy had been reported.[234] Oral TB manifests in 0.4%–1.5% of patients with pulmonary TB.[3] Primary isolated gingival TB is extremely rare and less documented.[578]

The pathogenesis of gingival TB can be attributed to self-inoculation in small mucosal tears with infected sputum followed by localization of organisms, with predisposing factors being poor oral hygiene, dental extraction, and leukoplakia.[6]

In our case report, the patient presented with a history of inadequate treatment for tuberculous glandular lymphadenitis. As the patient had gingival enlargement and poor oral hygiene, we decided to perform scaling and gingival curettage followed by gingivectomy. The excised tissue was sent for biopsy. Histopathological examination revealed the presence of noncaseating granulomas with multinucleated Langhans cells. MT-Tissue PCR was negative. The pulmonologist provisionally diagnosed the lesion as tuberculous granuloma and initiated antitubercular drug regimen, based on the previous history of tuberculous glandular lymphadenitis, elevated ESR, and the histopathological report. Six months after the treatment, the lesion involving the lip reduced in size with the gingiva displaying normal color and consistency, confirming the diagnosis of tuberculous gingival enlargement, primarily oral in origin. A similar case of oral tuberculous ulcer extending from mucogingival junction to the buccal sulcus in the lower jaw was also reported, where all the diagnostic tests including radiographs were negative.[5] Similar cases of primary isolated gingival TB which resolved with antitubercular regimen had been reported.[78]

In our case, orofacial granulomatosis was excluded as there was no history of allergen exposure or genetic history. Sarcoidosis was unlikely as the chest radiograph and serum angiotensin-converting enzyme levels were normal.

CONCLUSION

This is a case where a definite diagnosis of primary tuberculous gingival enlargement was made based on the medical history, hematological and histopathological findings, and response to anti-TB regimen, with confirmatory tests such as MT-Tissue PCR being negative. Gingival enlargement can be attributed to various medical conditions, and a dentist should take a proper medical history to correctly diagnose the underlying reason, which can provide useful information to a physician for treating it.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parents have given consent for images and other clinical information to be reported in the journal. The patient's parents understand that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.