Clinical Scenario

A 43‐year‐old male presents to the dental clinic complaining of generalised pain in his mouth of several years’ duration. He reports that the pain makes eating very difficult and feels that this is linked to his weight loss in the past year. You note that the patient is unable to communicate clearly and appears intoxicated.

Structured Learning

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 diagnosed
   • A 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 tuberculosis
     

     

   • 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 HIV
   • This 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 infections
   • Temporomandibular dysfunction
   • Depression/atypical facial pain
   • Chronic 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?
   • Social
     • Unrealistic expectations – the weight loss may be due to other factors, including the constitutional syndrome; orofacial pain may not be related to dental health
     • Impaired 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 visit
     • Limited commitment to attend the dental clinic/hospital and follow‐up
     • Limited financial means
   • Medical
     • Frail, malnourished patient with probable impaired wound healing
     • Recurrent tuberculosis
     • Impaired respiratory function: tuberculosis, mycetoma, asthma
     • Potential side‐effects of antituberculosis medication (infection/bleeding risk)
     • Visual impairment due to the cataract and potential blurred vision with tiotropium
   • Dental
     • Neglected mouth/poor commitment to maintaining oral health
     • Active smoking
     • Hyposalivation caused by tiotropium
5. What laboratory tests are recommended before undertaking the dental extractions?
   • Full blood count
     • Rifampicin can cause leucopenia and thrombocytopenia
     • Isoniazid is also associated with a risk of thrombocytopenia, anaemia, aplastic anaemia, haemolytic anaemia
     • Haematological alterations are not uncommon in protein malnutrition
   • Liver function tests
     • Isoniazid can cause toxic hepatitis
   • Coagulation study
     • Coagulation may be impaired due to hepatic dysfunction caused by antituberculosis drugs
     • Rifampicin 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 liver
   • Appropriate medications include:
     • Antibiotics such as penicillin V or amoxicillin
     • Analgesics: 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 infection
   • Hence treatment can proceed but it is prudent to liaise with the patient’s physician given the multiple comorbidities
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