Читать книгу A Practical Approach to Special Care in Dentistry - Группа авторов - Страница 163

1 Is it likely that the patient's tuberculosis was active a year ago and led to the development of the pulmonary mycetoma?It is more likely that the patient had latent tuberculosis rather than active tuberculosis disease when the mycetoma was diagnosedA pulmonary mycetoma is a chronic, progressively infectious disease which can occur within a pulmonary cavity that is usually generated during the previous episode of active tuberculosisFigure 4.1.1 Orthopantomogram showing multiple caries and alveolar bone loss.It consists primarily of fungi, especially of the genus Aspergillus

2 What risk factors does this patient have for the development of tuberculosis?The use of recreational drugs is known to increase the risk of contracting tuberculosis, whether or not the individual has HIVThis has been linked to the sharing of drug equipment, such as marijuana water pipes

3 What factors could be contributing to the patient's oral symptoms?Poor oral health/recurrent dental infectionsTemporomandibular dysfunctionDepression/atypical facial painChronic pain associated with constitutional syndrome

4 The patient requests that all his remaining teeth are removed and dental implants are placed so that he can eat 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