A 36-year-old female reported to the department of periodontics, Subharti Dental College, Meerut, U.P., with progressive, non-painful swelling of the upper anterior gingiva for the past 1 year.
The patient had a history of rising temperature in the evening and weakness over the past 4-5 months, loss of appetite, and a weight loss of about 5.5 kg during the past 10 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 good build, pulse temperature, and respiration rates were normal. The chest was clinically clear. Extraoral examination revealed no significant cervical lymphadenopathy. Intraoral examination showed diffuse enlargement of palatal mucosa and labial maxillary gingiva extending from right to left canines [Figures 1 and 2]. The color of the gingiva was fiery red. The surface was irregular and pebbled with ulcerations and discharge on both labial and palatal aspects. On palpation, the swelling was slightly tender and had a tendency for spontaneous bleeding on provocation. The rest of the oral cavity was normal.
Complete hemogram and IOPA X-rays were advised. Results of a complete blood count were within normal limits, except for a marginal rise in leukocyte count and an elevated erythrocyte sedimenta-tion rate (ESR). IOPA X-rays revealed slight crestal bone loss without any periodontal or periapical pathology [Figure 3].
The patient was then advised tuberculin test, chest X-ray, sputum culture, and immunoglobulins test for tuberculosis. A tuberculin (Montoux) test was positive, sug-gesting tubercular infection. Chest radiography (posteroan-terior view) revealed no abnormalities. Culture of sputum was negative for M. tuberculosis. An immuno-logic test to detect antibodies against Mycobacterium in the patient's serum (ELISA) was positive.
An incisional biopsyfrom the maxillary labial gingiva adjacent to the central incisors was performed. Histopathologic examination revealed clusters of epithelioid cells, caseating necrosis, and nume-rous Langhans-type giant cells surrounded by a chronic inflammatory type of infil-trate [Figure 4]. In view of these findings, a working diagnosis of primary tuberculous gingival enlargement was made.
On consultation with a physician, antituber-cular therapy was initiated with isoniazid (10 mg/kg body weight), rifampicin (10-20 mg/kg), pyrazinamide (20-35 mg/kg), and ethambutol (25 mg/kg) for 2 months followed by isoniazid (10 mg/kg) and rifampicin (10-20 mg/kg) for the following 4 months.
During this period, the patient was instructed not to undergo any surgical procedure within the oral cavity and was warned of transmitting the disease to others via salivary contamination. 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. This resulted in significant regression of the enlarged gingivae both labially and palatally.