Diagnosis and Treatment of a Rare Case of Tubercular Gingival Enlargement

ABSTRACT

Granulomatous inflammation is a distinctive variant of the chronic inflammatory response. The orofacial tissues may be affected by a wide range of granulomatous diseases. The lesions range from infections, immunological, and reactive, to foreign body granulomas. As is common knowledge, tuberculosis (TB) is a chronic infectious disease that can affect any region of the body, including the mouth. It may involve the tongue in the mouth and have quite peculiar features and forms. Therefore, while uncommon, oral lesions are crucial for the early detection and treatment of primary TB. We discuss a possible instance of gingival TB that manifested as an enlarged gingiva. The patient received a test dose of antituberculous therapy for one month. The antituberculous therapy was completed for the following five months after one month of treatment showed progress. This case report for dentists emphasizes how crucial it is to consider TB in the differential diagnosis of various types of gingival enlargements.

INTRODUCTION

An unusual variation of the chronic inflammatory response is granulomatous inflammation. A granuloma is a unique, compact microscopic structure made up of macrophages with epithelioid shapes often encircled by a rim of lymphocytes. It is rare to experience granulomatous inflammation of the oral soft and hard tissues.[1]

Typically, sessile, lobulated, somewhat hard, and relatively non-tender nodules and papules with normal color and little to no surrounding inflammatory mucosal erythema are the hallmarks of granulomatous lesions of the oral cavity.[2]

Multiple factors contribute to the etiology, which also includes infections, vasculitis, immunological disturbances, hypersensitivity, neutrophil oxidase defects, chemicals, and neoplasia.[3] Infections, foreign body responses, Crohn’s disease (CD), sarcoidosis, and orofacial granulomatosis (OFG) are examples of common differential diagnoses. Granuloma formation may also be related to other systemic disorders, though less frequently.[4] Even though oral TB signs are uncommon, they are thought to account for 0.1% to 5% of all TB infections. Oral TB lesions can occur as primary or secondary lesions. The oral symptoms of TB can also take the shape of patches, superficial ulcers, indurated soft-tissue lesions, or even lesions inside the jaw that could take the form of TB osteomyelitis or straightforward bony radiolucency.[5]

This article presents such a case report with the purpose to emphasize the importance of early diagnosis of TB of the oral cavity, particularly gingiva, which may be misdiagnosed when oral lesions are not associated with any apparent systemic infection.

CASE REPORT

A 50-year-old woman reported to the Department of Periodontology, Govt. Dental College and Hospital, Amritsar, with painful swelling of the gingiva, with profuse bleeding on slight provocation, especially on the upper and lower front gingival areas of the oral cavity. The patient gave a history of enlargement of the gingiva for the past four years, which was gradually increasing in size with time. The patient complained of a burning sensation in the mouth after having spicy food, bleeding while brushing teeth, and inflammation on the lips. The previous medical history of the patient reveals that the patient is type 2 diabetic, hypertensive, and hyperthyroid. The previous dental history of the patient reveals that the patient had undergone oral prophylaxis and the application of topical steroids with no relief.

Intraoral examination showed gingival ulceration and enlargement, especially in the upper and lower anterior labial and upper posterior buccal areas. The gingiva was fiery red, irregular, papillary, pebbled, and granular in appearance. The lesion was very painful on touch with spontaneous bleeding on provocation. The angle of mouth showed cheilitis on the left side. Tiny ulcers were present on the buccal mucosa on both sides as well. There was the presence of abundant local deposits, which were attributed to the patient’s inability to brush her teeth due to pain and discomfort. Extraoral examination revealed palpable lymph nodes with respect to the left submandibular region. There was swelling of the lips [Figure 1].

Figure 1.

Ulcerative lesions on buccal mucosa

A complete hemogram was performed and was within normal limits. A chest X-ray was advised to rule out pulmonary TB. All the radiographic results were found to be normal. The Mantoux test and the gold TB test were performed and were negative. Triple H viral test was negative. A serum angiotensin converting enzyme (ACE) enzyme test was performed to rule out sarcoidosis and the level was 55U/L, which was within the limits. Provisionally, anti-allergic therapy was started and vitamin A and E supplements were given. An incisional biopsy was performed on the upper labial gingiva in relation to the maxillary right central incisor. A biopsy showed small nodular tubercular granulomatous inflammation throughout the dermis. Granuloma consists of plasma cells, histiocytes, epithelioid cells, and occasional Langhans and foreign body giant cells. Overall epidermis showed moderate spongiotic psoriasiform changes. There were no organisms seen, and the periodic acid schiff (PAS) stain was negative for fungi.

Findings were suggestive of infective granuloma. The histopathological differential diagnosis was tuberculosis (TB) or rhinoscleroma. Following consultation with the general practitioner and dermatologist, an antitubercular therapy trial with isoniazid (10 mg/kg of body weight), rifampicin (10–20 mg/kg of body weight), and pyrazinamide (10–20 mg/kg of body weight) for one month was started based on all laboratory investigations and correlation with clinical examination. On follow-up after 40 days, significant progress in healing of the oral lesion with a reduction in inflammation and bleeding was observed [Figures 2 and 3]. The anti tuberculosis drug (ATT) was then extended for an additional five months. The patient was given specific instructions not to have any oral surgery during this time and was cautioned against the contagious nature of the disease [Figure 4].

Figure 2.

Ulcerative lesions on labial mucosa

Figure 3.

Marking for biopsy

Figure 4.

Immediate post-biopsy image

DISCUSSION

Granuloma production in the oral cavity can be related to several diseases. The most typical differential diagnosis includes OFG, infection, CD, sarcoidosis, and foreign body responses. Granulomatous inflammation may appear in the oral cavity and is typically accompanied by a variety of vague clinical symptoms. Granuloma development, which is a focal aggregation of inflammatory cells caused by the ongoing presence of a non-degradable product or hypersensitive reactions, is what distinguishes the diverse expression of granulomatous disorders from one another.[6]

They develop as a result of a robust immune system that produces inflammatory processes to eliminate invasive infectious organisms, which either cause the production of enormous cells or cause them to change into epithelioid cells. A microscopic diagnosis of granulomatous inflammation frequently poses a diagnostic conundrum for the clinician due to the generally generic clinical symptoms connected to these granulomatous disorders.[1]

According to Jain and Jain (2014), mycobacteria, most commonly Mycobacterium TB in humans, are the primary cause of TB, a chronic granulomatous disease. Primary oral tuberculous lesions are substantially more infrequent since they typically develop after early detection and treatment of TB elsewhere in the body.[5] Primary oral TB lesions typically affect adolescents and young adults. The most frequent way that oral TB manifests itself is as a tongue ulcer, followed by gingival involvement. It merits documenting because of the unusual clinical appearance and a higher likelihood of being missed during a regular intraoral examination.[7] It may also be in the form of superficial ulcers, patches, indurated soft-tissue lesions, or even lesions within the jaw that may be in the form of TB osteomyelitis or simple bony radiolucency. Of all these oral lesions, the ulcerative form is the most common. It is often painful, with no caseation of the dependent lymph nodes.[8]

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Conflicts of interest

There are no conflicts of interest.