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CDHO Advisory: Tuberculosis, Infection or Disease









Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with tuberculosis, infection or disease.


Cite as College of Dental Hygienists of Ontario, CDHO Advisory Tuberculosis, Infection or Disease, 2024-04-14


Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).



Tuberculosis, infection or disease


Advanced practice nurses
Dental assistants
Dental hygienists
Health professional students
Public health departments
Regulatory bodies


To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have tuberculosis, infection or disease, chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Record keeping.
  9. Advising the patient/client.


Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged, 80 and over
Parents, guardians, and family caregivers of children, young persons and adults with tuberculosis, infection or disease.


For persons who have tuberculosis, infection or disease2: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.



Terminology used in this Advisory

Resources consulted

  1. Tuberculosis, infectious disease caused by Mycobacterium tuberculosis, abbreviated to M. tuberculosis.

Other terminology

  1. Tuberculosis disease, in which Mycobacterium tuberculosis becomes active and creates disease in 
    1. the lungs
    2. other parts of the body, including
      1. lymph nodes
      2. kidneys
      3. urinary tract
      4. bones and joints. 
  2. TB disease, synonym for tuberculosis disease.
  3. Active tuberculosis, former term used in Canada instead of current “tuberculosis disease”.
  4. Active TB, synonym for active tuberculosis (i.e., tuberculosis disease).
  5. Active TB disease, synonym for active tuberculosis (i.e., tuberculosis disease).
  6. Drug-resistant tuberculosis and multi-drug resistant anti-tuberculosis drug resistance is a major public health problem that threatens the success of the global approach for detection and cure of tuberculosis, as well as global tuberculosis control.
  7. Immunocompromised, state in which a person’s immune system is deficient or absent, which
    1. acts to
      1. impair the body’s defences against infection 
      2. increase the immunocompromised person’s risk of serious infections and severe complications 
      3. increase the risk of opportunistic infections, which do not normally afflict healthy individuals
    2. is caused by or related to
      1. infections, such as HIV/AIDS (CDHO Advisory)  
      2. certain cancers, including 
        1. leukemia (CDHO Advisory)  
        2. lymphoma (CDHO Advisory)  
      3. chemotherapy (CDHO Advisory)  
      4. radiation therapy (CDHO Advisory)  
      5. chronic diseases, such as
        1. end stage renal disease with dialysis (CDHO Advisory)  
        2. diabetes (CDHO Advisory)  
        3. cirrhosis (CDHO Advisory)  
      6. inherited genetic defects 
      7. medications, such as 
        1. steroids
        2. post-transplant immunosuppression.
  8. Immunosuppression (CDHO Advisory), suppression of immunity with medications, the uses of which include the treatment of certain autoimmune diseases, such as rheumatoid arthritis; its main drawbacks are the increased risk of infection and, in the case of tuberculosis, the reactivation and/or spread of disease for the duration of immunosuppression therapy.
  9. Tuberculosis infection, in which Mycobacterium tuberculosis lodges in the lungs (usually) and lies dormant, causing no symptoms and no active disease.
  10. TB infection, synonym for tuberculosis infection.
  11. Latent tuberculosis infection (LTBI), former term used in Canada instead of current “tuberculosis infection”.
  12. Latent TB, synonym for latent tuberculosis (i.e., tuberculosis infection).
  13. Inactive tuberculosis, synonym for latent tuberculosis (i.e., tuberculosis infection).
  14. Inactive TB, synonym for latent tuberculosis (i.e., tuberculosis infection). 
  15. Lesion, a term variously and loosely used in medicine to refer to such things as
    1. any abnormality of tissue in the body, including the mouth and skin
    2. any localized abnormal structural change in a bodily part
    3. a mass especially before a definite diagnosis is established
    4. cancer
    5. an injury to living tissue, such as a cut or break in the skin.
  16. Mantoux test, tuberculin skin test (TST), PPD (purified protein derivative) test, used to identify persons infected with Mycobacterium tuberculosis.
  17. Oral ulcer, an open lesion, often painful, inside the mouth or upper throat, an alternative name for 
    1. a mouth ulcer
    2. an aphthous ulcer
    3. aphthous stomatitis, also known as a canker sore
    4. a cancerous ulcer.
  18. Palliative care, services of care for persons towards the end of life with terminal illnesses, when the focus of the care 
    1. is relieving symptoms
    2. attending to physical and spiritual needs.
  19. Supportive care, services of care to help persons meet the physical, emotional and spiritual challenges arising from the condition or its treatment.

Overview of tuberculosis, infection or disease

Resources consulted 

Tuberculosis, infection or disease

  1. Is contagious, but some persons are more at risk than others.
  2. Is reported in Canada at the globally low rate of 1,829 new cases per year (2021 statistics).
  3. Is considered one of the deadliest infectious diseases worldwide, especially in developing countries; according to the World Health Organization
    1. among infectious diseases, tuberculosis is the greatest contributor to adult mortality, causing approximately 1.4 million deaths per year worldwide in 2019
    2. one-quarter of the world’s population is infected with Mycobacterium tuberculosis (mostly in less-developed countries) which, given globalization, trans-national migration and tourism, means that all countries are potential targets for outbreaks of tuberculosis
    3. drug-resistant tuberculosis is a serious and growing problem.
  4. Infects usually via the respiratory tract, the commonest route of entry of Mycobacterium tuberculosis.
  5. Is spread by exhalation spray from a person with tuberculosis disease (i.e., active tuberculosis)
    1. as in coughing 
    2. to which, to become infected, an uninfected person would require exposure 
      1. to exhalation spray from an infected person 
      2. usually extended over hours per day for a protracted period.
  6. Is well controlled in Canada, but some Canadians contract it, see also comorbidity and persons at risk, including 
    1. persons with HIV/AIDS (CDHO Advisory)  
      1. creates the most important risk factors for tuberculosis infection and active tuberculosis 
      2. substantially increases the risk of developing disease tuberculosis: a person with both tuberculosis infection and HIV/AIDS is 50–170 times more likely to develop disease tuberculosis than someone who does not have HIV/AIDS
    2. persons who have or have had close contact with individuals with known or suspected disease tuberculosis, such as family members sharing living spaces
    3. persons who have lived or worked in countries where tuberculosis is common 
    4. persons with a weakened immune system, and various medical conditions
    5. many First Nations and Inuit Canadians
    6. the elderly
    7. the homeless 
    8. residents of long-term care facilities
    9. residents of correctional facilities
    10. staff of correctional facilities
    11. persons who live in unhygienic conditions in crowded housing
    12. health professionals when exposed to persons with disease tuberculosis
  7. Is characterized by
    1. a cough that lasts two to three weeks or more, especially if productive of sputum or blood
    2. fever
    3. night sweats 
    4. weight loss 
    5. loss of appetite
    6. constant fatigue.
  8. Is diagnosed by 
    1. tuberculin skin (Mantoux, PPD) test3 or TB blood test4, as appropriate
    2. chest x-ray, and sputum collection5, to detect lung disease or signs of previous disease infection.

Comorbidity, complications and associated conditions; persons at risk

Comorbid conditions are those which co-exist with tuberculosis, infection or disease, but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice. 

A major consideration with tuberculosis, infection or disease, or its comorbidities, complications or associated conditions is the possibility of their putting other persons at risk of infection with tuberculosis.

Resources consulted

In tuberculosis, whether disease or infection, the comorbidity and complications reflect common factors such as those that lead to debilitation. In combination, these correspond to conditions that put persons at high risk of progression of infection tuberculosis to disease tuberculosis.

  1. Persons at high risk for progressing from infection tuberculosis to disease tuberculosis include
    1. persons infected with HIV/AIDS (CDHO Advisory)
    2. persons infected with Mycobacterium tuberculosis within the previous 2 years 
    3. infants and children aged <4 years 
    4. persons with any of the following clinical conditions or other immunocompromising conditions 
      1. silicosis 
      2. diabetes (CDHO Advisory)  
      3. chronic renal failure (CDHO Advisory 
      4. end-stage renal disease (CDHO Advisory)  
      5. certain hematologic disorders, such as
        1. leukemia (CDHO Advisory)  
        2. lymphoma (CDHO Advisory)  
      6. other specific malignancies such as cancer of the
        1. head
        2. neck
        3. lung
      7. body weight >10 percent below ideal body weight 
      8. prolonged corticosteroid use (CDHO Advisory)
      9. immunosuppressive treatments 
      10. organ transplantation (CDHO Fact Sheet)
      11. intestinal bypass or gastrectomy 
    5. persons with a history of untreated or inadequately treated tuberculosis, including persons with chest radiograph findings consistent with previous tuberculosis.
  2. Persons who might be at increased risk for infection and disease include
    1. users of 
      1. tobacco or alcohol (CDHO Advisory)  
      2. drugs of abuse by injection, such as crack cocaine (CDHO Advisory)  
      3. injections of steroids
    2. those with
      1. clinical depression (CDHO Advisory)  
      2. other chronic medical conditions associated with social and environmental factors, such as chronic obstructive pulmonary disease (CDHO Advisory), which active tuberculosis accompanies, and which are important determinants of clinical outcomes.

Oral health considerations 

Resources consulted 

  1. A person with tuberculosis infection is not contagious so can be treated in the dental office under standard infection control precautions.
  2. Any persons with signs/symptoms suggestive of tuberculosis disease should be
    1. promptly removed from the area of other patients/clients or staff, instructed to wear a surgical or procedure mask
    2. assessed for the urgency of their dental care
    3. immediately referred for medical care.
  3. Standard precautions are insufficient to prevent transmission of Mycobacterium tuberculosis
  4. Elective dental treatment should be deferred until the person has been declared non-contagious by a physician. Urgent dental care for a person with suspected or disease tuberculosis should be provided in a facility that has
    1. the capacity for isolation from airborne infection 
    2. a respiratory protection program in place.
  5. When treating a person with tuberculosis disease, dental healthcare personnel should
    1. use respiratory protection, such as fitted, disposable N-95 respirators 
    2. be aware that standard surgical face masks are not designed to protect against airborne transmission of Mycobacterium tuberculosis. 


Sourcing medications information

  1. Adverse effect database
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements 
  5. Complementary and alternative medicine

Types of medications


Individual medications may be subject to important warnings, which

  1. change from time to time
  2. may affect the appropriateness, efficacy or safety of the Procedures
  3. are accessible via the links to the particular medications listed below or through the specialized organizations listed above
  4. through the links, should be viewed by dental hygienists in the course of their familiarizing themselves about a medication or combination of medications identified in the patient/client’s medical and medications history.


The most common anti-tuberculosis drugs, often taken in combination are:
isoniazid (INH, generics)
rifampin (RMP, Rifadin®, Rimactane®)
rifapentine (Priftin®)
pyrazinamide (PZA)
ethambutol (EMB, Myambutol®)

Less commonly used drugs for treatment of tuberculosis in Canada include:
amikacin (Amikin®)
rifabutin (RBT, Mycobutin®)

Streptomycin is not available in Canada, but it is still used as part of first-line therapy in a few countries. Fluoroquinolones (FQN; moxifloxacin, levofloxacin) are alternative medications for treatment of TB.

Side effects of medications

  1. Drug resistance, which arises from improper use of antibiotics for tuberculosis patients, and which results from
    1. administration of incorrect treatment regimens by health-care workers 
    2. failure to ensure that persons complete the whole course of treatment 
    3. generally poor tuberculosis control programmes.
  2. Multidrug-resistant tuberculosis is a specific form of drug-resistant tuberculosis in which Mycobacterium tuberculosis bacilli are resistant to at least isoniazid and rifampin, two of the first-line anti-tuberculosis drugs. 
  3. For the side effects of particular medications see the links above.


The medical  and medications history-taking should 

  1. Focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. medications considerations
    3. contraindications
    4. complications
    5. comorbidities.
  2. Explore the need for advice from the appropriate primary or specialized care provider(s).
  3. Inquire about
    1. where the patient/client is receiving or has received medical care for tuberculosis
    2. the patient/client’s understanding and acceptance of the need for oral healthcare
    3. the type of information and advice needed from the appropriate primary care provider(s)
    4. current medications
      1. pertaining to tuberculosis
      2. other medications, including over-the-counter medications, herbals and supplements
    5. problems with previous dental/dental hygiene care
    6. problems with infections generally and specifically associated with dental/dental hygiene care
    7. the patient/client’s current state of health
    8. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
      3. recent changes in the patient/client’s condition.


Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

  1. Record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number.
  2. Obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider.
  3. Use a consent/medical consultation form, and be prepared to securely send the form to the provider.
  4. Include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.


Infection control, tuberculosis, infection and disease

Resources consulted

  1. Public Health Ontario/Provincial Infectious Diseases Advisory Committee’s Best Practices for Infection Prevention and Control Programs in Ontario
    1. strongly recommends all healthcare workers have a baseline TB screening, including:
      1. individual risk assessment that identifies risks for TB (temporary or permanent residence in a high-incidence country, prior TB, current or planned immune suppression or close contact with someone who has had infectious TB since the last tuberculin skin test)
      2. a symptom evaluation
      3. tuberculin skin test for those without documented prior TB disease or TB infection.
    2. recommends, in most cases, a two-step baseline tuberculin skin test for all healthcare workers in all healthcare settings6
    3. recommends healthcare workers with a positive tuberculin skin test be assessed for active TB disease, including a chest x-ray and a medical evaluation, including consideration for treatment of TB infection by a physician experienced in management of TB and TB infection; they should also be educated on the signs and symptoms of TB
    4. addresses prevention and control of tuberculosis transmission in healthcare settings (Chapter 14).
  2. Under the Center for Disease Control and Prevention (CDC) Guidelines’ definitions7
    1. all personnel with duties that involve face-to-face contact with patients/clients with suspected or confirmed tuberculosis disease should be included in a tuberculosis screening program 
    2. dental-care staff comprise all paid and unpaid persons working in dental healthcare settings who have the potential for exposure to Mycobacterium tuberculosis through air space shared with persons with TB disease
    3. part-time, temporary, contract, and full-time dental-care staff should be included in tuberculosis screening programs.

Infection control generally

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2024)
  2. relevant occupational health and safety legislative requirements
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client.


The dental hygienist 

  1. should not implement the Procedures without prior consultation with the appropriate primary or specialist care provider(s) if the patient/client has TB disease 
  2. may postpone the Procedures pending medical advice if the patient/client 
    1. appears debilitated or has symptoms or signs of comorbidity, complication or an associated condition, or of exacerbation of the medical condition
    2. has a history suggestive of TB disease or a past history suggestive of inadequately treated TB disease 
    3. has a history suggestive of conversion from TB infection to currently active TB
    4. has not complied with pre-medication, including antibiotic prophylaxis, as directed by the prescribing physician
    5. recently changed significant medications, under medical advice or otherwise
    6. has complications or comorbidities of tuberculosis about which the dental hygienist is in need of additional information and advice
    7. recently experienced changes in his/her medical condition such as medication or other side effects of treatment
    8. is unable to provide the dental hygienist with sufficient information about
      1. his or her personal medical history
      2. medications
      3. treatment 
    9. has not recently or ever sought and received medical advice relative to oral healthcare procedures
    10. is deeply concerned about any aspect of his or her medical condition. 


Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid provisions and responses as required for current certification in first aid.


Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2)

For a patient/client with a history of tuberculosis, infection or disease, the dental hygienist should specifically record

  1. A summary of the medical and medications history.
  2. Any advice received from the physician/primary care provider relative to the patient/client’s condition.
  3. The decision made by the dental hygienist, with reasons.
  4. Compliance with the precautions required.
  5. All Procedure(s) used.
  6. Any advice given to the patient/client.


The patient/client is urged to alert any healthcare professional who proposes any intervention or test that he or she has a history of tuberculosis, infection or disease.

As appropriate, discuss 

  1. The importance of the patient/client’s
    1. taking medication(s) as prescribed for pre-medication including antibiotic prophylaxis.
    2. self-checking the mouth regularly for suspicious signs or symptoms
    3. reporting to the appropriate healthcare provider any changes in the mouth indicative of suspicious lesions.
  2. The need for regular oral health examinations and preventive oral healthcare. 
  3. Oral self-care including information about 
    1. choice of toothpaste
    2. tooth-brushing techniques and related devices
    3. dental flossing
    4. mouth rinses
    5. management of a dry mouth. 
  4. The importance of an appropriate diet in the maintenance of oral health.
  5. For persons at an advanced stage of a disease or debilitation
    1. regimens for oral hygiene as a component of supportive care and palliative care
    2. the role of the family caregiver, with emphasis on maintaining an infection-free environment through hand-washing and, if appropriate, wearing gloves
    3. scheduling and duration of appointments to minimize stress and fatigue. 
  6. Comfort level while reclining, and stress and anxiety related to the Procedures.
  7. Medication side effects such as dry mouth, and recommend treatment.
  8. Mouth ulcers and other conditions of the mouth relating to tuberculosis, infection or disease, comorbidities, complications, medications or diet.
  9. Pain management.



  1. Promoting health through oral hygiene for persons who have tuberculosis, infection or disease.
  2. Reducing risk of spread of tuberculosis from persons with active tuberculosis to dental-office staff and patients/client by
    1. applying the protocols and guidelines specific to tuberculosis risk
    2. using appropriate techniques of communication
    3. providing advice on scheduling and duration of appointments.
  3. Reducing the risk that oral health needs are unmet.


  1. Causing harm by failing to apply measures needed to combat the spread of tuberculosis from persons with tuberculosis infection.
  2. Performing the Procedures at an inappropriate time, such as 
    1. when a patient/client is in the phase of spreading Mycobacterium tuberculosis by exhalation spray
    2. in the presence of complications or comorbidities for which prior medical advice is required
    3. in the presence of acute oral infection without prior medical advice.
  3. Disturbing the normal dietary and medications routine of a person with tuberculosis, infection or disease.
  4. Inappropriate management of pain or medication.






2010-07-15; 2020-05-11; 2024-04-14


College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists


College of Dental Hygienists of Ontario


College of Dental Hygienists of Ontario, Practice Advisors


Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow

Lisa Taylor

Elaine Powell

Kyle Fraser
RDH, BComm, BEd, MEd

Carolle Lepage


The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2009, 2010, 2020, 2024 College of Dental Hygienists of Ontario


1 Persons includes young persons and children.
2 The 2022 Canadian Tuberculosis Standards (8th edition) replaced the long-standing terms “active TB disease” and “latent TB infection (LTBI)” with “TB disease” and “TB infection” respectively.
3 A person with a “positive” tuberculin skin test (as defined a certain number of millimetres of induration [hardness] in the transverse diameter on the forearm, according to certain risk criteria) and no signs/symptoms/proof of active disease has TB infection, not TB disease. This person is not contagious to others and cannot transmit TB.
4 TB blood test = interferon gamma release assay (IGRA)
5 Two to three sputum samples are typically submitted for TB smear, PCR (polymerase chain reaction) test, and culture.
6 A baseline two-step tuberculin skin test should be done unless there is documentation of a prior negative two-step test, in which case a single-step test should be done. (Tuberculin skin testing involves intradermal injection of an antigen called purified protein derivative [PPD].) CTBS 2022 also states that recommendations for periodic and serial (repeated) tuberculin skin testing for healthcare workers vary with the setting, but periodic (repeated) testing is no longer routinely recommended for all healthcare workers.
7 CDC recommendations (2019, updating 2005) for screening and testing healthcare personnel (HCP) include an individual baseline (preplacement) risk assessment, symptom evaluation and testing of persons without prior TB disease or TB infection, no routine serial testing in the absence of exposure or ongoing transmission, treatment for HCP diagnosed with TB infection, annual symptom screening for persons with untreated TB infection (i.e., LTBI), and annual TB education of all HCP.