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  • Transmission is by infected airborne droplets of mucous or saliva expelled from the lungs by coughing, sneezing and talking

  • Transmission is rarely by fomites

  • Only 5-10% of cases arise at the time of initial infection - all others are reactivation of dormant tubercule.

  • Determinants of disease contraction

    • Number of organisms inhaled

    • Level of immuncompetence of exposed person

  • Incubation period is widely variable

  • Primary pulmonary TB develops in minority whose immune systems do not contain the primary infection and may occur within weeks after primary infection

  • TB may lie dormant when the host defenses control and contain the primary infection - results in latent TB infection (LTBI)

  • Patients with LTBI are not contagious

  • LTBI may progress to secondary or reinfection TB with delayed reactivation of persistent dormant viable bacilli.  This is usually confined to the lungs.  Reasons for reactivation:

    • Immunosuppressive agents (chemotherapy)

    • Immunodeficiency disease (e.g., AIDS)

    • Transplant recipients

    • Age (infants and elderly

Tuberculosis

Introduction

Concerns of the Dentist for patients with TB

Dental Management

  • A patient with diagnosed or undiagnosed TB is highly contagious and could pass the disease on to the dentist and/or their staff

  • Patient being treated for TB is at risk for drug induced hepatitis

  • Other medications used to treat TB interact with drugs used in dentistry

Questions to Ask 

  • Mantoux tuberculin skin test

    • Several causes of false negatives

      • If it is within the first 6-8 weeks of the infection - incubation phase

      • If the patient is immunocompromised

      • In 10-25% of people with active TB

    • A positive skin test always indicates the patient has been infected, but not if the patient has an active infection

  • Additional tests on patients with a positive TST to determine if it is active

    • Positive acid-fast bacillus sputum smear

    • History of cough and weight loss

    • Positive chest x-ray

Diagnostic Tests 

  • See "Dental Management"

Clinical Findings 

  • Patient has active sputum-positive tuberculosis

    • Consult with physician before treatment

    • If patient has urgent needs

      • Palliate with medication only if possible.  

      • If a handpiece is required for palliative treatment, treat only in a hospital setting with special respiratory protection

    • If patient has been under treatment with appropriate chemotherapy for at leaset 2-3 weeks, request confirmation from physician that the patient is non-infectious - patient can be treated as a healthy patient

  • Patient reports a past history of tuberculosis

    • Determine if the patient is currently infective

      • Diagnosis dates and treatment dates

      • Patients can be considered non-infective if

        • The patient was treated for 18 months in past decades

        • The patient was treated for at least 6 months recently and as much as 18 months if they have multi-drug resistant TB

        • The patient has symptoms consistent with relapse.

      • Consult with physician before treatment

    • If the patient is currently infective, follow guidelines for the patient with active TB above

    • If the patient is not currently infective, they can be treated as a healthy dental patient

  • Patient reports a positive tuberculin test

    • View this patient as having been infected with TB

    • The patient should have additional history of chest x-ray, physical examination and sputum culture

    • If these are negative, the patient can be considered to have latent tuberculosis infection

    • These patients are only treated for TB if they are considered to be at risk for disease progression

    • These patient may be treated as healthy dental patients.

  • Patients with signs and symptoms suggestive of TB

    • Symptoms

      • Cough, pleuritic chest pain

      • Fatigue

      • Fever

      • Night sweats

      • Unexplained weight loss

      • Malaise

      • Hemoptysis (occurs only in 20%)

      • Dyspnea

    • History

      • Positive TST with no follow-up care

      • Contact with patients with active TB

    • Refer to physician for evaluation

    • Follow the guidelines for the patient with active TB and urgent dental needs above

References

Dental Management of the Medically Compromised Patient.  Little, Falace, Miller and Rhodus. 8th Edition

Medical Consultation Recommended 

  • See "Dental Management" below

  • Cough, pleuritic chest pain

  • Fatigue

  • Fever

  • Night sweats

  • Unexplained weight loss

  • Malaise

  • Hemoptysis (occurs only in 20%)

  • Dyspnea

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