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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 31  |  Issue : 3  |  Page : 270-273

Tuberculous granuloma of the gingiva – A forgotten entity


1 Department of Oral Medicine and Radiology, Geetanjali Dental and Research Institute, Udaipur, Rajasthan, India
2 Department of Oral Pathology and Microbiology, Geetanjali Dental and Research Institute, Udaipur, Rajasthan, India

Date of Submission20-Apr-2019
Date of Acceptance12-Jun-2019
Date of Web Publication30-Sep-2019

Correspondence Address:
Dr. M S Archana
Department of Oral Medicine and Radiology, Geetanjali Dental and Research Institute, Geetanjali University Campus, Hiran Magri Extension Chouraha, Udaipur - 313 001, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_90_19

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   Abstract 


Tuberculosis (TB) claims to be one of the most deadly communicable diseases. Mycobacterium tuberculosis is identified as the causative micro-organism. Extrapulmonary TB is quite rare, of which oral TB lesions account to less than 1% and exists as primary and secondary lesions. In recent times, the number of cases reported with extrapulmonary TB is on the rising trend due to an increase in the number of immunocompromised patients. To highlight the extrapulmonary oral TB lesion, we hereby present a case report on oral TB.

Keywords: Extrapulmonary tuberculosis, gingival ulcer, granuloma, oral tuberculosis


How to cite this article:
Archana M S, Babu A, Prasad B V, Verma M. Tuberculous granuloma of the gingiva – A forgotten entity. J Indian Acad Oral Med Radiol 2019;31:270-3

How to cite this URL:
Archana M S, Babu A, Prasad B V, Verma M. Tuberculous granuloma of the gingiva – A forgotten entity. J Indian Acad Oral Med Radiol [serial online] 2019 [cited 2019 Dec 14];31:270-3. Available from: http://www.jiaomr.in/text.asp?2019/31/3/270/268282




   Introduction Top


Tuberculosis (TB) is a chronic granulomatous communicable infection of global health concern. Although being an old disease, TB is still one among ten leading causes of deaths across the world. Advances in chemotherapeutic agents and improvement in nutrition had led to a decline in the incidence of TB cases worldwide. Recent surveys show an upward trend in the number of cases possibly due to the development of drug-resistant strains and due to the emergence of HIV seropositive patients.[1] Incidence of TB cases in India according to WHO 2018 report was 27% of overall TB burden worldwide (highest among the 30 high TB burden countries).[2] Lungs are the most affected; extrapulmonary TB involving the central nervous system, ileocecal, hepatosplenic, genitourinary system, lymph nodes, peritoneum and musculoskeletal regions are not very uncommon.[3] Oral TB lesions account to less than 1% of the extrapulmonary TB cases reported.[1] As extrapulmonary TB lesions lack classic presentation, these lesions are frequently overlooked.

This case report of a 21-year-old female who presented with a solitary ulcer in the oral cavity highlights the importance and awareness of oral TB lesions among healthcare professionals.


   Case Report Top


A 21-year-old female patient reported to the Oral Medicine and Radiology clinic with a complaint of an ulcer on the gingiva in relation to the upper front teeth with duration of six months. History of this illness revealed that the ulcer was noticed six months back, a maintained a constant size and was associated with mild pain. There was no evening rise in temperature or weight loss reported. The patient visited many dental physicians who advised her topical medications and root canal treatment for teeth 11, 12, 21 and 22 suspecting the lesion was of tooth origin. There was no sign of healing of the ulcer even after the use of topical medications for five months. A history of trauma during childhood was reported by the patient.

The medical and family history was non-contributory. The patient revealed a history of consuming Arecanut (Supari) in childhood for duration of 1–2 months. On palpation, the right and left submandibular lymph nodes were enlarged, non-tender, and mobile. Intraorally, tooth 11 was discoloured and oral hygiene was satisfactory.

A solitary well-defined ulcer was identified on the attached gingiva i.r.t. 11, 12, 13, and 14. Ulcer measured about 3 cm × 1.5 cm with the margin being irregular and the edge was raised. The floor showed a corrugated appearance with slough covering the surface. Mucosa surrounding it was erythematous. On palpation, inspectory findings were confirmed, and the ulcer was tender with mild bleeding [Figure 1].
Figure 1: Clinical view: Ulcerative lesion in the attached gingiva i.r.t 11, 12, 13, 21

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Based on these clinical findings, a tentative diagnosis of chronic non-healing ulcer was considered. Differential diagnosis included for the same were malignant ulcer and solitary ulcers due to fungal and bacterial infections. An intra-oral radiograph of teeth 11, 12, 21, and 22 and an incisional biopsy of the lesion was indicated. Teeth 11 and 21 were root canal treated [Figure 2]a and [Figure 2]b.
Figure 2: (a) Intra-oral periapical view showing the absence of bone involvement with root canal treated 11. (b) Intra-oral periapical view showing the absence of bone involvement with root canal treated 11, 21

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Incisional biopsy specimen measuring about 0.7 × 0.6 mm was taken from the periphery of the lesion. Tissue was stained with hematoxylin and eosin stains. On scanner view under 4 × magnification, the section showed ulcerated epithelium and underlying connective tissue stroma [Figure 3]a. Low-power view under 10 × magnification confirms the presence of ulcerated epithelium and connective tissue storma [Figure 3]b. High-power view of the section showed stratified squamous epithelium exhibiting ulceration. Few areas in the underlying connective tissue stroma exhibited the formation of granuloma consisting of central necrosis, surrounded by epithelioid cells, lymphocytes and multinucleated giant cells resembling Langhans giant cells. Connective tissue stroma exhibited dense infiltration of mixed inflammatory cell infiltrate consisting of neutrophils, plasma cells, and lymphocytes. Few blood vessels and extravasated red blood cells were also evident [Figure 3]c. These above histopathological features were suggestive of Granulomatous Tuberculous ulcer of gingiva.
Figure 3: (a) Photomicrograph showing ulcerated epithelium and connective tissue stroma (Hematoxylin and eosin stain, original magnification x4). (b) Photomicrograph showing caseating necrosis surrounded by epitheloid cells, plasma cells, and lymphocytes (Hematoxylin and eosin stain, original magnification x10). (c) Photomicrograph showing langhans cells, epitheloid cells, and lymphocytes (Hematoxylin and eosin stain, original magnification x40)

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Correlating the clinical and histopathological features the lesion was diagnosed as tuberculous granuloma of gingiva. Routine haematological investigation showed elevated erythrocyte sedimentation rate (32 mm/1st hour Wintrobe). Further investigations namely chest radiograph and Mantoux test were indicated. Mantoux test was positive with chest radiograph showing no positive features [Figure 4]. A diagnosis of extrapulmonary TB involving the oral cavity specifically the gingiva was considered. The patient was referred to the Department of Tuberculosis and Chest for further management. She was advised anti-tubercular regimen which included Isoniazid (H), Rifampicin (R), Pyrazinamide (Z) and Ethambutol (E) for a duration of two months followed by a regimen of Isoniazid (H), Rifampicin (R) and Pyrazinamide (Z) for four months, dosage based on the body weight of the patient. She was followed up every two months. By the end of two months of anti-Tubercular therapy [ATT], there were signs of healing of the ulcer [Figure 5]a. Follow up by the end of four months, the ulcer had completely healed [Figure 5]b.
Figure 4: Chest radiograph shows no signs of consolidation

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Figure 5: (a) Shows healing tuberculous ulcer (two months). (b) Shows healed tuberculous ulcer (four months)

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   Discussion Top


TB is caused by Mycobacterium tuberculosis, an aerobic, non-motile, non-capsulated, non-spore forming acid fast bacilli. TB is also caused by exposure of Mycobacterium bovis, through ingestion of cow milk in rare cases.[4] History of TB dates back to centuries. In Egyptian mummies, spinal TB was known as “Kings's evil”. In parts of Europe, TB was referred to as “White plague” as it led to 900 deaths per 100,000 population.[5] Although commonly affecting lungs, it is also known to cause infection in extrapulmonary sites. Innes in 1981[6] briefed the mechanism of extrapulmonary TB infection. They include non-pulmonary TB infection, lymphatic spread, and haematogenous spread from the primary complex, haematogenous spread from post-primary complex, contiguous spread from organ to organ and implantation on epithelial surfaces.

Oral TB lesions are kept on a check due to the integrity of oral mucosa, antagonism of striated muscles, and protective effects of saliva facilitated by the presence of salivary lysozymes, tissue antibodies, and saprophytes. However, any breach in the surface epithelium as small tears caused by chronic inflammation or trauma can result in colonization of tubercle bacilli in the mucosa. Oral TB lesions are the result of self-inoculation with infected sputum due to constant coughing or direct inoculation through haematogenous spread has also been reported.[7]

Local and systemic factors also play a crucial role in the occurrence of oral TB lesions. Local factors include poor oral hygiene, trauma, and pre-existing lesions like leukoplakia, periapical granuloma, abscess, cyst, and periodontitis. Immune suppression and nutritional deficiencies are contributory systemic factors.[8] Family history also plays an important role in TB. In this case report, there was no positive family history which is in contrast to the case reported by Vankadara S et al. In the present case, medical history was not significant, which was similar to the case reported by JingtaPK et al., Vankadara S et al., and Ju et al.[7],[9],[10]

Oral TB lesions can occur as primary or secondary lesions. Oral TB lesions do not have a definite site predilection. Most lesions are seen on tongue. Other sites include lips, palate, gingiva, buccal mucosa, palatine tonsil, and floor of the mouth.[11],[12] TB lesions in the oral cavity present as slow growing, single, indurated, irregular, radiating, superficial, or deep painful ulcer with undermined edges covered by inflammatory exudates. Other clinical presentations include nodules, fissures, tuberculomas, and granulomas. Lesions may be single or multiple, painful or painless. Skin, cervical lymph nodes, and salivary glands are also frequently involved. TB may involve the jaws causing tuberculous osteomyelitis or rarefying osteitis.[1],[4],[5]

In this case, patient presented with a solitary ulcer on the gingiva with no systemic symptoms similar to a case reported by JingtaPK et al.[9] Mobility of the teeth and extensive bone loss was reported by JingtaPK et al.,[9] which was in contrast with the present case.

Primary lesions are relatively uncommon affecting young adults presenting as solitary painless indolent ulcer extending from the gingival margin to the depth of adjacent vestibule with regional lymphadenopathy [submandibular submental and cervical]. Secondary lesions are concurrent with pulmonary TB, commonly affecting adults and elderly patients.[5]

Even with an increase number of oral TB cases reported, clinicians still face challenges in diagnosis due to the lack of pathognomonic signs. Since most early lesions resemble a neoplasm or inflammatory lesion, due to the lack of systemic manifestations anti-inflammatory treatment and surgical resection are advocated. Oral TB lesions are considered only when the primary treatment rendered is ineffective and fails to resolve the lesion.[3] Other lesions that can be considered as a differential diagnosis for a chronic non-healing ulcer are malignancy, ulcers in HIV infection, Cicatricial pemphigoid, Syphilis, and deep mycotic infection such as Histoplasmosis, Wegener's granulomatosis, and Sarcoidosis.[13]

Various investigations can be used to diagnose TB, which include medical imaging, Ziehl Neelsen staining, testing the patient's immune response [tuberculin skin testing – Mantoux Test and interferon gamma release assays], histopathology.[14] Biopsy from oral lesions remains the gold standard for confirmation of oral TB lesions. Multiple biopsies are warranted as in most of cases a single biopsy may not reveal granulomatous lesions in early disease.[7] The histopathological presentation in TB is mainly due to cell-mediated hypersensitivity reaction. Granuloma formation is seen in the area of infection along with epithelioid cells, lymphocytes, and multinucleated giant cells. A single granuloma is called as “tubercle”. Langhans giant cells show a horseshoe-shaped arrangement of the nuclei.[15] Due to the scarcity of tubercle bacilli in oral biopsies, the efficiency of demonstration of acid-fast bacilli in histological specimens is low. However, negative results do not rule out the possibility of TB.[5] PCR is the most advanced diagnostic procedure to identify Mycobacterium tuberculosis DNA.[5]

After the diagnosis is confirmed, the patient is referred to the specialist to commence systemic ATT. World Health Organization in 1997 launched a global strategy for TB control known as “Directly Observed Therapy Shortcourse” [DOTS]. Traditional ATT called quadritherapy includes isoniazid, rifampicin, pyrazinamide, and ethambutol that have shown favourable response. Quadritherapy is given for two months intensive phase followed by continuation phase for four months.[15],[16] Two primary factors that make TB control a difficult process are persistence and resistance for which the drug treatment time should be extended for the complete destruction of bacteria and to prevent relapse.[17]

Dental professionals are at a high risk of being exposed to TB by means of infected blood, aerosols, or splatters. Only emergency dental procedures are carried out in active TB cases. Elective procedures are deferred until the TB lesion has completely resolved.


   Conclusion Top


Oral TB lesions are relatively rare and have become a forgotten diagnosis among oral mucosal lesions. This article reports an example of primary tuberculous granuloma occurring in the oral cavity which was diagnosed in the early stages. Oral TB though rare should be included in the differential diagnosis of solitary oral ulcers more so in tropical countries. Oral physicians play a vital role in the early detection of TB.

In the absence of any local causes for a single ulcers in the oral cavity, mandatorily a systemic co-relation should be explored which facilitates early diagnosis and treatment resulting in a complete cure.

Declaration of patient consent

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

Acknowledgements

The authors would like to thank the Department of Tuberculosis and Chest Medicine, Geetanjali Medical College and Hospital, Udaipur, Rajasthan, India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Konstantinos A. Testing for tuberculosis. Aust Prescr 2010;33:8-12.  Back to cited text no. 14
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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