|Year : 2015 | Volume
| Issue : 1 | Page : 45-48
Primary isolated gingival tuberculosis: A rare case report
Pravesh Kumar Jhingta1, Deepak Sharma1, Vinay Kumar Bhardwaj2, Prem Machhan3, Neelam Gupta4, Sanjeev Vaid5
1 Department of Periodontology, Himachal Pradesh Government Dental College and Hospital, Shimla, India
2 Department of Public Health Dentistry, Himachal Pradesh Government Dental College and Hospital, Shimla, India
3 Department of Medicine, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India
4 Department of Pathology, Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh, India
5 Department of Orthopaedics and Dentofacial Orthopaedics, Himachal Pradesh Government Dental College and Hospital, Shimla, India
|Date of Web Publication||13-Jan-2015|
Pravesh Kumar Jhingta
Department of Periodontology, Himachal Pradesh Government Dental College and Hospital, Shimla - 171 001, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Tuberculosis is an inflammatory granulomatous systemic disease that rarely presents as primary lesions in gingiva. Gingival involvement has been reported in only a very limited number of cases. A case of primary tuberculosis affecting gingiva and alveolar mucosa is presented. A 20-year-old female patient presented with multiple gingival ulcers, necrotic slough over the gingiva in maxillary arch facially and palatally, and bone destruction. The patient had no evidence of tuberculosis elsewhere. The diagnosis was made following a gingival biopsy. An incisional biopsy with polymerase chain reaction (PCR) and Ziehl Nielsen (ZN) staining was consistent with the diagnosis of gingival tuberculosis. The patient was subsequently referred to the physician for clinical management and the condition resolved with active antitubercular treatment. It is concluded that tuberculosis is a systemic disease that rarely affects the gingiva. The possibility of gingival involvement as sole manifestation of the disease should be considered in the differential diagnosis of gingival lesions
Keywords: Antitubercular treatment, gingiva, Langhans cells, mycobacterium tuberculosis
|How to cite this article:|
Jhingta PK, Sharma D, Bhardwaj VK, Machhan P, Gupta N, Vaid S. Primary isolated gingival tuberculosis: A rare case report. Int J Health Allied Sci 2015;4:45-8
|How to cite this URL:|
Jhingta PK, Sharma D, Bhardwaj VK, Machhan P, Gupta N, Vaid S. Primary isolated gingival tuberculosis: A rare case report. Int J Health Allied Sci [serial online] 2015 [cited 2021 May 18];4:45-8. Available from: https://www.ijhas.in/text.asp?2015/4/1/45/149268
| Introduction|| |
Tuberculosis (TB) is a chronic granulomatous infectious disease caused by Mycobacterium tuberculosis. Primary oral tuberculous lesions are much rarer, as early diagnosis and treatment of TB elsewhere in the body may be the reason for its uncommon presentation.  Primary oral TB lesions generally occur in young adults. Tongue ulcer is the commonest form of presentation of oral TB, followed by gingival involvement. Rare clinical presentation and increased chance of being overlooked during routine intraoral examination make it worthy of documentation. Although the incidence of disease is continuously decreasing, TB still remains a major health problem, especially in developing countries.  The purpose of this article is to emphasize the importance of early diagnosis of primary TB of oral cavity and especially of gingiva, which may be misdiagnosed when oral lesions are not associated with any apparent systemic infection.
| Case report|| |
A 20-year-old female reported to the Department of Periodontology, with painful ulcerations of the gingiva in maxillary anterior region and palate. She complained of discomfort and bleeding from the gingiva, while eating and brushing. The patient noticed ulcerations in gingiva in maxillary anterior teeth about 6 months ago with mobility of maxillary right lateral incisor. The ulcerations rapidly involved adjacent regions after exfoliation of right lateral incisor after 2 months. Her medical history revealed no systemic problems and she was apparently healthy with no cough or expectoration, fever, or weight loss. There was no cervical lymphadenopathy or any other abnormal findings. The patient never visited a dentist in her lifetime and had no history of dental trauma or any surgery.
On intraoral examination there were gingival ulcerations involving marginal and attached gingiva, alveolar mucosa in the maxillary canine to canine region, right second premolar - first molar region facially, and palatal mucosa of left premolar - molar region [Figure 1],[Figure 2] and [Figure 3]. The gingiva was fiery red, with necrotic slough and was painful on touch with spontaneous bleeding on provocation. There was severe soft and hard tissue destruction with denuded roots of the anterior teeth along with moderate to severe mobility. The amount of destruction was not commensurate with the local factors. There was incomplete healing of the wound in exfoliated right lateral incisor region.
|Figure 1: Tuberculous ulcers involving marginal and attached gingiva, alveolar mucosa in the maxillary canine to canine region|
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|Figure 2: Tuberculous ulcers involving marginal and attached gingiva, palatal mucosa of left premolar-molar region|
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|Figure 3: Tuberculous ulcers involving marginal and attached gingiva, right second premolar- first molar region facially|
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A clinical differential diagnosis of acute necrotizing ulcerative Gingivitis, syphilis, human immunodeficiency virus (HIV), TB, and actinomycosis was made. Complete hemogram, enzyme-linked immunosorbent assay (ELISA) for HIV, antinuclear antibody (ANA), chest radiograph (posteroanterior (PA) view), and intraoral occlusal and intraoral periapical radiographs were advised. Results of complete blood count were within normal limits and HIV test was negative. Erythrocyte sedimentation rate was elevated (34 mm) and ANA was negative (5.8 units). No lesions were detected in chest radiograph. Intraoral radiographs showed extensive bone loss with respect to maxillary anterior teeth [Figure 4].
|Figure 4: Radiographs showing extensive bone loss with respect to maxillary anterior teeth|
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Incisional biopsy was performed on the gingiva in relation to maxillary left lateral incisor, canine, and palatal mucosa of posterior region. Histopathological examination showed necrotizing granulomatous inflammation with Langhans type giant cells on ulcerated mucosa [Figure 5]. On Ziehl-Neelsen (ZN) staining, acid-fast bacilli were demonstrated and imprint gingiva showed cellular mass revealing predominantly neutrophils in sheets, a few lymphocytes, plasma cells, benign superficial cells, and epithelioid cell granulomas. The features were suggestive of tuberculous granulomatous lesion [Figure 6].
|Figure 5: Necrotizing granulomatous inflammation with Langhans type giant cells on ulcerated mucosa|
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Consultant physician has started the antitubercular therapy with isoniazid, rifampicin, and pyrazinamide drugs for 2 months followed by isoniazid and rifampicin for the following 4 months. During the period, the patient was instructed not to undergo any surgical procedure within the oral cavity. However, patient responded well to the conservative periodontal therapy with minimal trauma to gingiva [Figure 7].
| Discussion|| |
TB is a reemerging infectious granulomatous disease caused mainly by Mycobacterium tuberculosis, an acid-fast bacillus that is transmitted primarily via the respiratory route. According to the World Health Organization, TB is responsible for death of approximately 2 million people each year and it is estimated that between 2002 and 2020, approximately 1 billion people will be newly infected, over 150 million people will get sick, and 36 million will die because of TB. It remains a major health problem in most developing countries. Among the world population, the Southeast Asian countries carry 88% of world's burden of TB. 
Lesions of TB in the oral mucosa are seldom primary, but rather secondary to pulmonary disease. Farber et al., indicated that less than 0.1% of the patients whom they examined, exhibited oral lesions.  Tongue is most affected followed by palate, buccal mucosa lips, salivary glands, tonsils, uvula, and mandibular ridge. The most common occurring lesion is an ulcer, characterized by irregular edges with minimal indurations. The base of an ulcer may be granular or covered with pseudomembrane. ,
Primary oral TB that usually involves gingiva may present as diffuse, hyperemic, nodular or papillary proliferation of the gingival tissues, or an irregular, superficial or deep, painful ulcer which tends to increase in size. Primary oral TB is usually associated with regional lymphadenopathy. 
The mechanism of primary inoculation is unknown. However, it is thought that the Mycobacterium is inoculated directly into the oral mucosa. The intact oral mucous membrane presents a natural resistance to Mycobacterium invasion. This resistance has been attributed to the cleansing action of saliva; the presence of salivary enzymes, tissue, antibodies, and oral saprophytes; and the thickness of the protective epithelial covering. Any break or loss of this natural barrier, which may be result of trauma, inflammatory conditions, tooth extraction, or poor oral hygiene, may provide a route of entry for the Mycobacterium. Diffuse involvement of the maxilla and mandible may also occur, usually by hematogenous spread of infection, but sometimes by a direct extension or even after tooth extraction. ,, In this patient there was a rapid spread of the lesions after exfoliation of maxillary right lateral incisor. However, in those areas of the world where unpasteurized milk is consumed, bovine tubercle bacilli often cause human infection. This patient lived on a farm where the consumption of unboiled or raw milk is common and, presumably she had consumed infected milk. It is vital for clinician to conduct a complete physical examination including signs and symptoms of pulmonary TB with various diagnostic tests and by performing a biopsy. Histopathological study is needed to exclude carcinomatous changes and to confirm the diagnosis of TB.
Since the introduction of effective chemotherapy, tuberculous lesions of the oral cavity have become so infrequent that it is virtually a forgotten disease entity and pose a diagnostic problem. They account for less than 1% of cases of extrapulmonary TB, and are usually associated with foci of disease elsewhere in the body. , It should be considered in the differential diagnosis, particularly in a nonhealing lesion that does not respond to the usual therapy. Thus, a periodontist can contribute in early diagnosis and prompt treatment of infectious disease as TB. 
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]