Department of Pediatric Dentistry
Resident’s Name:Murphy Program:Lutheran Medical Center - Providence

Article title: Resurgence of TB in children
Author(s): Stake MD, Jeffrey.
Journal: The Journal of Pediatrics
Year. Volume (number). Page #’s: 1992. 120. 839-851
Major topic: TB in children
Minor topic(s): TB and the dental setting
Overview of method of research: Clinical review

Findings: The clinical expression of infection due to Mycobacterium tuberculosis differs substantially in children compared with adults. There are three basic stages of the disease: exposure, infection, and disease. Children infected prior to age 4 have a very high rate of developing immediate clinical or radiographic manifestations or both, but are unlikely to develop reactivation disease in adulthood. In contrast, children infected in preadolescence or adolescence are more prone to developing more severe adult-type pulmonary tuberculosis soon after infection or in adulthood. The most common symptoms associated with TB are cough, fever, wheezing, and failure to gain weight. Clinical signs of TB are surprisingly meager, but rales and wheezes over the affected lung field are most common.

Diagnosis
The Mantoux TST(aka PPD), which uses five tuberculin units of purified protein derivative, is the standard method for detecting infection by M. tuberculosis. The reaction is measured as millimeters of induration after 48 to 72 hours. Since TST is the only way to determine asymptomatic infection by M. tuberculosis, the false-negative rate cannot be calculated. A negative TST does not rule out TB disease in a child. If the test is positive, a chest x-ray is taken to either confirm on deny infection. TB in chest radiographs show enlargement of hilar, mediastinal, or subcarinal lymph nodes and lung parenchymal changes. The role of bronchoscopy in evaluating children for TB is controversial.
Treatment
A 6-mo regiment consisting of isoniazid(INH), rifampin, and pyrazinamide given for 2 mo followed by isoniazid and rifampin for 4 mo is the preferred treatment for patients with fully susceptible organisms who adhere to treatment. Ethambutol (or streptomycin in children too young to be monitored for visual acuity) should be included in the initial regimen until the results of drug susceptibility studies are available, unless there is little possibility of drug resistance

Dental Treatment and TB
Because a person with latent TB is not infectious, he or she can be treated in the dental office under standard infection control precautions.2
Any patient with symptoms suggestive of active TB disease should be removed from the area of other patients or staff, instructed to wear a surgical or procedure mask, assessed for the urgency of their dental care and promptly referred for medical care. Standard precautions are insufficient to prevent transmission of the bacterium. Elective dental treatment should be deferred until the patient has been declared non-infectious by a physician. Urgent dental care for a person with suspected or active TB should be provided in a facility that has the capacity for airborne infection isolation and has a respiratory protection program in place. OSHA describes a standard for respiratory protection, which should be consulted if setting up a program. When treating a patient with active TB, dental health care personnel should use respiratory protection (e.g., fitted, disposable N-95 respirators). Standard surgical face masks are not designed to protect against TB transmission. The CDC recommends that dental office personnel receive training and education on M. tuberculosis and TB disease that emphasizes the increased risks posed by an undiagnosed person with TB disease in a dental-care setting and the specific measures to reduce this risk. The CDC also recommends that dental offices perform an annual risk assessment. People in the dental office who have the potential for exposure to M. tuberculosis through air space shared with persons with infectious TB disease (which essentially means all personnel) receive a two-step baseline tuberculin skin test (TST) at the beginning of employment in low-risk settings, every 12 months in medium-risk settings and every 8–10 weeks in the event of potential ongoing transmission until no further evidence of ongoing transmission is apparent.

Assessment of Article: Good article. Kind of old. I also used www.ada.org for additional info, which was very helpful.


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