A Practical Approach to Special Care in Dentistry

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

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

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)

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.