A Practical Approach to Special Care in Dentistry. Группа авторов

properly and gain weight. What factors should you consider when assessing the risk of managing this patient?SocialUnrealistic expectations – the weight loss may be due to other factors, including the constitutional syndrome; orofacial pain may not be related to dental healthImpaired capacity due to apparent intoxication – this may be linked to use of recreational drugs; unable to give informed consent, needs to be assessed at each visitLimited commitment to attend the dental clinic/hospital and follow‐upLimited financial meansMedicalFrail, malnourished patient with probable impaired wound healingRecurrent tuberculosisImpaired respiratory function: tuberculosis, mycetoma, asthmaPotential side‐effects of antituberculosis medication (infection/bleeding risk)Visual impairment due to the cataract and potential blurred vision with tiotropiumDentalNeglected mouth/poor commitment to maintaining oral healthActive smokingHyposalivation caused by tiotropium

      5 What laboratory tests are recommended before undertaking the dental extractions?Full blood countRifampicin can cause leucopenia and thrombocytopeniaIsoniazid is also associated with a risk of thrombocytopenia, anaemia, aplastic anaemia, haemolytic anaemiaHaematological alterations are not uncommon in protein malnutritionLiver function testsIsoniazid can cause toxic hepatitisCoagulation studyCoagulation may be impaired due to hepatic dysfunction caused by antituberculosis drugsRifampicin has also been associated with impaired vitamin K production by oral flora; this reduces the activity of vitamin K‐dependent clotting factors

      6 You determine that there is acute infection associated with #27. What do you need to consider when prescribing antibiotics and/or analgesics?Do not prescribe medication that is metabolised by the liverAppropriate medications include:Antibiotics such as penicillin V or amoxicillinAnalgesics: such as metamizole (unavailable in some countries) or paracetamol at low dosages (<2 g/day)

      7 When planning for dental extractions, should you delay due to the diagnosis of tuberculosis?The patient has undergone tuberculosis treatment for more than 3 months following reactivation of the infectionHence treatment can proceed but it is prudent to liaise with the patient's physician given the multiple comorbidities

      8 The patient asks whether he can have sedation for dental extractions. What precautions are necessary with this patient?Advise that this cannot be provided if recreational drugs are usedConsider the BMI/weight loss of the patientDuring the active phase of tuberculosis, do not use nitrous oxide as this might contaminate the gas flow systemLorazepam has synergistic action with other benzodiazepinesThe concomitant use of rifampicin and diazepam should be avoided

      General Dental Considerations

      Oral Findings

       The most common oral lesion is a chronic ulcer located on the dorsum of the tongue (although it can also appear on the palate, lips, oral mucosa and gums) (Figure 4.1.2)

       Diagnosis is established based on a biopsy of the lesion

       Cervical or submandibular tuberculous lymphadenopathyOften caused by nontuberculous mycobacteriaA number of these mycobacteria are multiresistant, particularly among patients with HIV infectionLymphadenopathy can fistulise the skin surface (scrofula)Figure 4.1.2 Primary tuberculosis manifesting as a non‐healing, tender ulcer on the tip of the tongue.Diagnosis is established through cultures and/or polymerase chain reaction (PCR) of the nodule biopsyTreatment usually consists of administering clarithromycin and excising the affected nodules

       There have been reported oral findings related to tuberculostatic agents:Rifampicin and rifabutin can stain the saliva redRifampicin can cause lichenoid hypersensitivity lesionsStreptomycin can cause circumoral paraesthesia

      Dental Management

       The dental treatment plan will be determined primarily by the disease progression and by the presence of comorbidities (e.g. HIV infection) (Table 4.1.1)

Section II: Background Information and Guidelines

      Definition

Tuberculosis is an infectious and transmissible disease caused by Mycobacterium tuberculosis, which is characterised by necrotising granulomatous inflammation that mainly affects the lungs (approximately 85% of cases). It is estimated that tuberculosis infects approximately 10 million individuals worldwide each year, 87% of which are concentrated in only 30 countries (predominantly countries with low economic levels). It is a notifiable disease in many parts of the world, with healthcare staff required to inform their health protection teams of a suspected/confirmed case.

Table 4.1.1 Considerations for dental management.

Risk assessment	Mycobacteria proliferate in the biofilms of dental unitsAlthough the risk of transmission is low, the transmission of tuberculosis in the dental clinic has been reportedPatients who start antituberculosis therapy are considered to not be infectious at 2 weeks, although negative sputum results might not start for up to 2 monthsPatients who have completed antituberculosis therapy generally have no risk of disease reactivationSide‐effects of tuberculosis medication:Especially in those older than 35 years, drug‐induced hepatitis can increase the tendency to bleedLeucopenia, thrombocytopenia and impaired vitamin K production (increasing bleeding risk) have also been describedA number of comorbidities can affect the delivery of dental treatment (alcoholism, drug addiction, hepatitis and HIV infection)
Criteria for referral	Latent tuberculosisThe patient is not infectious and can be treated in the dental clinic using standard infection control precautionsActive tuberculosisStandard precautions are insufficient to prevent bacterial transmissionUrgent dental treatment should be undertaken in a hospital setting with access to the appropriate personal protective equipment and ideally a negative pressure roomNon‐urgent treatment should be postponed for 3 monthsReferral to a specialised clinic or hospital centre is also determined by the patient's general condition (e.g. respiratory distress or concurrent advanced HIV infection)
Access/appointment	As routine, healthcare staff within the dental clinic should have tests for tuberculosis and evidence of immunity; this is evidenced by tuberculin skin testing or interferon gamma testing within the last 5 years, and/or checking of a BCG (cacillus Calmette–Guérin) scar by an occupational health professionalIf the patient has active tuberculosis, schedule the appointment for the last session of the day to minimise the risk of cross‐transmission; ensure there is access to filtering face pieces (FFP) – ideally FFP3 as these have the highest level of filtering capacityMinimise the number of staff in contact
Consent/capacity	Include any potential risks arising from the drugs used to treat tuberculosis and/or comorbidities
Anaesthesia/sedation	Local anaesthesiaNo specific recommendations; this is the method of choice to enable dental treatmentSedationAvoid sedation with nitrous oxide (risk of contamination)Consider the impact of respiratory depressionThe efficacy of diazepam can change in patients who are administered rifampicinAccelerated metabolism and reduced plasma concentrations of benzodiazepines have been notedGeneral anaesthesiaGeneral anaesthesia entails a risk of contamination, and some patients also have pulmonary function impairmentStreptomycin increases the activity of neuromuscular blockers (myasthenic syndrome)Where unavoidable, a plenum‐ventilated operating theatre should be used
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