Dental Management for TB Patients
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Questions and Answers

What is indicated for the treatment of secondary hyperparathyroidism in patients with chronic kidney disease who are on dialysis?

  • Radiation therapy
  • Parathyroidectomy
  • Bisphosphonates
  • Calcimimetics (correct)

    • Which situation warrants a parathyroidectomy?

  • Secondary hyperparathyroidism that is refractory to medical therapy (correct)
  • Primary hyperparathyroidism without symptoms
  • Secondary hyperparathyroidism controlled by medication
  • Patients with mild hyperparathyroidism

    • Which of the following could be a cause of non-PTH-mediated hypercalcemia?

  • Familial hypocalciuric hypercalcemia
  • Secondary hyperparathyroidism
  • Hypercalcemia of malignancy (correct)
  • Transient hyperparathyroidism

    • Which dental complication is associated with hyperparathyroidism?

    <p>Generalized bone rarefaction</p> Signup and view all the answers

    What is the preferred method of pain control in dental treatments for patients with hyperparathyroidism?

    <p>Local anesthesia</p> Signup and view all the answers

    What type of respirators should be used by personnel providing urgent treatment to patients with suspected or confirmed TB?

    <p>P100 respirators</p> Signup and view all the answers

    Which procedure is recommended for patients with clinically active sputum-positive TB?

    <p>Consult a physician before treatment</p> Signup and view all the answers

    What precaution should be taken before treating a patient with a past history of TB?

    <p>Obtain a thorough medical history</p> Signup and view all the answers

    How should patients under the age of 6 with active TB be treated?

    <p>As normal patients after verification of status</p> Signup and view all the answers

    When treating a patient with a positive tuberculin test, what should be verified?

    <p>Evaluation by a physician to rule out active disease</p> Signup and view all the answers

    What should be done if a patient with a past history of TB shows signs of relapse?

    <p>Postpone treatment and consult a physician</p> Signup and view all the answers

    What type of cleaning procedure is advised in a dental setting for areas exposed to TB patients?

    <p>Disinfecting and cleaning exposed surfaces</p> Signup and view all the answers

    Which statement regarding treatment for patients with consistent negative sputum is correct?

    <p>Treat as normal patients</p> Signup and view all the answers

    What is the main function of glucagon in the human body?

    <p>Raises the concentration of glucose and fatty acids in the bloodstream</p> Signup and view all the answers

    Which cells in the islets of Langerhans produce glucagon?

    <p>α-cells</p> Signup and view all the answers

    When is glucagon released in the body?

    <p>Under stress</p> Signup and view all the answers

    What inhibits the secretion of insulin and glucagon?

    <p>Somatostatin</p> Signup and view all the answers

    What type of hormone is somatostatin classified as?

    <p>Peptide hormone</p> Signup and view all the answers

    Which of the following regarding the half-life of somatostatin is true?

    <p>It is between 1-3 minutes</p> Signup and view all the answers

    Where is ghrelin produced in the human body?

    <p>ε-cells in the islets of Langerhans</p> Signup and view all the answers

    How does glucose stimulate somatostatin secretion?

    <p>By activating δ-cells to fire action potentials</p> Signup and view all the answers

    What skeletal abnormality is characterized by masses of reactive fibrous tissue due to increased osteoclast activity?

    <p>Brown tumors</p> Signup and view all the answers

    Which of the following is a gastrointestinal symptom associated with hyperparathyroidism?

    <p>Obstipation</p> Signup and view all the answers

    Which of the following is NOT typically a feature of osteoporosis as seen in untreated hyperparathyroidism?

    <p>Severe muscle weakness</p> Signup and view all the answers

    What is a common neuropsychiatric symptom associated with hyperparathyroidism?

    <p>Personality changes</p> Signup and view all the answers

    Which clinical feature is most indicative of a hyperparathyroid crisis?

    <p>Loss of consciousness</p> Signup and view all the answers

    What condition may present with bone pain in patients with chronic kidney disease?

    <p>Secondary hyperparathyroidism</p> Signup and view all the answers

    Which ECG change is commonly associated with hyperparathyroidism?

    <p>Short QT interval</p> Signup and view all the answers

    Which of the following is associated with tertiary hyperparathyroidism?

    <p>Increased risk of fractures</p> Signup and view all the answers

    Which laboratory findings indicate secondary hyperparathyroidism (sHPT) not caused by chronic kidney disease (CKD)?

    <p>↑ PTH and ↓ calcium</p> Signup and view all the answers

    What is a common indication for surgical therapy in hyperparathyroidism?

    <p>Serum calcium level &gt; 1 mg/dL above normal</p> Signup and view all the answers

    Which medication acts by increasing the sensitivity of calcium-sensing receptors in the parathyroid glands?

    <p>Cinacalcet</p> Signup and view all the answers

    When should imaging studies be conducted for patients who do not undergo parathyroid surgery?

    <p>Every 1-2 years</p> Signup and view all the answers

    What is the mechanism of action of bisphosphonates in managing bone density issues?

    <p>Inhibition of bone resorption</p> Signup and view all the answers

    What laboratory finding is commonly associated with tertiary hyperparathyroidism (tHPT)?

    <p>↑ PTH and ↑ calcium</p> Signup and view all the answers

    What should be monitored in patients undergoing pharmacotherapy for hyperparathyroidism?

    <p>BMD and serum calcium levels</p> Signup and view all the answers

    Which of the following is NOT an indication for total parathyroidectomy?

    <p>Solitary adenoma</p> Signup and view all the answers

    In managing secondary and tertiary hyperparathyroidism, how should underlying conditions like chronic kidney disease be addressed?

    <p>By managing vitamin D status</p> Signup and view all the answers

    What condition is indicated by a T-score of -2.5 at any site?

    <p>Osteoporosis</p> Signup and view all the answers

    Study Notes

    Respiratory Protection Controls

    • Use respiratory protection (N95, N99, or N100 respirators) for dental personnel treating suspected or confirmed TB patients.
    • Instruct TB patients to cover their mouth when coughing and to wear a surgical mask.

    Dental Management for Patients with a History of TB

    • Patients with clinically active sputum-positive TB should be consulted with a physician before treatment.
    • Urgent care only, with medication if a contained hospital facility is not available:
      • Urgent care with handpiece use (patients over 6) in a hospital setting with isolation, sterilization, and special respiratory protection.
      • Treat those less than 6 years of age as normal.
      • Treat patients consistently producing negative sputum as normal.
    • Patients with a past history of TB require a thorough history of disease, treatment duration, and an appropriate review of systems.
    • Obtain a history of periodic chest radiographs and physical examination to rule out reactivation or relapse.
    • Consult with a physician and postpone treatment if any of the following are identified:
      • Questionable adequacy of treatment time
      • Lack of appropriate medical follow-up evaluation since recovery
      • Sign or symptom of relapse
    • Treat as a normal patient if present status is "free of clinically active disease."
    • Patients with a positive tuberculin test or positive IGRA require physician evaluation to rule out active disease.

    Glucagon

    • 29 amino acid hormone
    • Main catabolic hormone in the human body
    • Secreted as proglucagon, a 160 amino acid polypeptide precursor that gives rise to glucagon, glucagon-like peptide 1 (GLP-1), and other peptides.
    • Produced by the α-cells in the islets of Langerhans
    • Elevated under stress
    • Released when blood glucose is too low, causing glycogenolysis in the liver
    • Increases energy expenditure
    • Raises the concentration of glucose and fatty acids in the bloodstream

    Somatostatin

    • Polypeptide hormone with two active forms: 14 amino acids and 28 amino acids
    • Produced by the δ-cells in the islets of Langerhans
    • Works on α- and β-cells in a paracrine manner
    • Also produced by the pyloric antrum and duodenum
    • Half-life is between 1-3 mins
    • Inhibits secretion of insulin and glucagon
    • Glucose stimulates δ-cells to fire action potentials and secrete somatostatin
    • Produces predominantly neuroendocrine inhibitory effects

    Ghrelin

    • 28 amino acid polypeptide hormone
    • Produced by the ε-cells in the islets.
    • Stimulates growth hormone release from the anterior pituitary gland
    • Plays a role in regulating appetite and energy balance

    Primary Hyperparathyroidism (pHPT)

    • Consider pHPT in patients with hypercalcemia.
    • Diagnostic confirmation:
      • High PTH and low calcium: sHPT
      • High PTH (or inappropriately normal) and high calcium: tHPT

    Secondary Hyperparathyroidism (sHPT)

    • No unique clinical presentation
    • Patients with CKD can present with bone pain
    • Cases associated with vitamin D deficiency present with related symptoms:
      • Osteomalacia, increased fractures
      • Myopathy

    Tertiary Hyperparathyroidism (tHPT)

    • Bone pain
    • Pruritus
    • Fatigue/lethargy
    • Increased risk of fractures

    Hyperparathyroidism Diagnostics

    • Consider pHPT in patients with hypercalcemia.
    • Laboratory studies:
      • High PTH and low calcium: sHPT
      • High PTH (or inappropriately normal) and high calcium: tHPT
    • Additional studies:
      • Low phosphate: sHPT not caused by CKD
      • Normal or high phosphate: sHPT caused by CKD
      • High phosphate: tHPT
      • High ALP: sign of bone turnover
      • High creatinine and low vitamin D: signs of CKD-MBD (Chronic kidney disease–mineral and bone disorder)

    Hyperparathyroidism Disease Management

    Primary Hyperparathyroidism (pHPT)

    • Management should be guided by a specialist.
    • Provide treatment for hypercalcemia.
    • Refer all symptomatic patients and eligible asymptomatic patients for surgical evaluation.
    • For patients who do not undergo surgery:
      • Start pharmacotherapy
      • Monitor for complications
    Surgical Therapy
    • Indications: symptomatic patients, and asymptomatic patients who meet the following criteria
      • Age < 50 years
      • Hypercalcemia: serum calcium level > 1 mg/dL above the upper limit of normal
      • Renal involvement:
        • Estimated GFR < 60 mL/minute
        • Hypercalciuria
        • Nephrolithiasis or nephrocalcinosis on imaging
      • Skeletal involvement:
        • Reduced BMD (T-score ≤-2.5 at any site)
        • Vertebral fracture
    • Surgical procedures:
      • Minimally invasive parathyroidectomy of the affected gland– for Solitary adenoma
      • Total parathyroidectomy with reimplantation of half a gland in easily accessible muscle - for Hyperplasia
      • Tumor resection with removal of the ipsilateral thyroid lobe and enlarged lymph nodes in cases involving Carcinoma
    Pharmacotherapy
    • Calcimimetics (e.g., cinacalcet): increases the sensitivity of calcium-sensing receptors in parathyroid glands to circulating Ca2+ → inhibition of PTH release
    • Bisphosphonates (e.g., alendronate): for patients with osteopenia or osteoporosis
    • Denosumab: alternative to bisphosphonates
    • Vitamin D supplementation: For patients with vitamin D deficiency or insufficiency
    Monitoring
    • Indication: patients who do not undergo parathyroid surgery
    • Imaging studies every 1–2 years:
      • DXA with VFA to assess BMD
      • Renal imaging (e.g., abdominal CT without contrast, renal ultrasound) to assess for nephrolithiasis and/or nephrocalcinosis
    • Laboratory studies yearly:
      • Serum calcium, 25-hydroxyvitamin D, creatinine, estimated GFR
      • 24-hour urine calcium

    Secondary & Tertiary Hyperparathyroidism

    • Treatment of the underlying condition:
      • Manage chronic kidney disease” and “CKD-MBD
      • In patients with vitamin D deficiency: Supplement with vitamin D analogues (e.g., ergocalciferol).
    • Calcimimetics:
      • For treatment of sHPT in patients with CKD who are on dialysis
      • Consider for patients with tHPT
    • Parathyroidectomy:
      • Consider for sHPT refractory to medical therapy.
      • Mainstay of treatment for tHPT

    Hyperparathyroidism Differential Diagnosis

    Primary Hyperparathyroidism (pHPT)

    • Other causes of PTH-mediated hypercalcemia: i.e., tHPT, familial hypocalciuric hypercalcemia
    • Causes of non-PTH-mediated hypercalcemia: e.g., hypercalcemia of malignancy, granulomatous disorders.

    Secondary & Tertiary Hyperparathyroidism

    • Other causes of hypercalcemia
    • Other causes of hypocalcemia
    • Other causes of hyperphosphatemia

    Hyperparathyroidism Dental Considerations

    • Dental changes in hyperparathyroidism include loss of the lamina dura and generalized bone rarefaction
    • Brown tumors are indistinguishable from central giant cell granulomas of the jaws – If giant cell lesion is found, particularly in a middle-aged patient or in a patient with CKD, parathyroid function should be investigated.
    • LA is the main means of pain control, especially if hypertension and arrhythmias are present.
    • Conscious sedation is preferably carried out with nitrous oxide and oxygen.
    • GA may be challenging because of cardiovascular complications and sensitivity to muscle relaxants.
    • Dental treatment in hyperparathyroidism may be complicated by renal disease, peptic ulceration, bone fragility or pluriglandular disease.

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    Description

    This quiz covers essential protocols for dental personnel treating patients with tuberculosis (TB). It includes guidelines for respiratory protection, treatment approaches for various age groups, and the importance of consulting with a physician. Review the key aspects that ensure safety and effective management of TB patients in dental settings.

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