Professional Documents
Culture Documents
Donald J Burden
Orthodontic Division, The Queen’s University of Belfast, UK
Jonathan Sandler
Chesterfield Royal Hospital NHS Foundation Trust, UK
The orthodontic treatment of patients with medical disorders is becoming an increasing aspect of modern day practice. This
article will draw attention to some of the difficulties faced when orthodontic treatment is provided and will make
recommendations on how to avoid potential problems.
Key words: Medical disorders, orthodontics, guidelines
2
Patel et al.
National Insitute
for Health and
European Society of Cardiology French Guidelines British Society for Antimicrobial American Heart Association Clinical Excellence
2004 2002 Chemotherapy 2006 2007 2008
High-risk patients Prosthetic heart valve, complex Previous IE. Cardiac Previous IE. Cardiac valve Prosthetic valve. Previous IE. Previous IE.
congenital cyanotic heart diseases. valve replacement. replacement. Prosthetic systemic Unrepaired or incompletely Acquired valvular
Previous IE. Prosthetic systemic Prosthetic systemic or pulmonary shunt or conduit. repaired cyanotic congenital heart disease with
or pulmonary shunt or conduit. or pulmonary shunt heart disease (CHD). CHD stenosis/regurgitation.
Mitral valve prolapse with valvular or conduit. repaired with prosthetic Prosthetic valve.
regurgitation/severe valve thickening. material for 6 months after Structural CHD
Non cyanotic congenital heart procedure. Valve disease in including surgically
diseases including bicuspid aortic cardiac transplant recipients corrected or palliated
valves. Hypertrophic cardiomyopathy structural defect
excluding isolated
atrial septal defect,
fully repaired
ventricular septal
defect or fully
Clinical Section
repaired patent
ductus arteriosus,
and closure devices
deemed to be
endothelialised.
Hypertrophic
cardiomyopathy
Low-risk patients Secundum type artial septal defect Other valve disease –
mitral valve prolapse
with mitral insufficiency,
valve thickening. Non-
cyanotic CHD except
Atrial septal defect.
Hypertrophic obstructive
cardiomyopathy
Dental procedures Dental procedures with risk of All invasive dental All invasive dental procedures Dental procedures involving None
requiring prophylaxis gingival/mucosal trauma procedures manipulation of gingival tissue,
in high-risk patients periapical area of teeth or
JO December 2009
perforation of oral mucosa.
Dental procedures None Optional – based on None None None
requiring prophylaxis clinical assessment of
in moderate- and low- patient and procedure.
risk patients Can be given post-op if
procedure unduly complex
JO December 2009 Clinical Section Medical disorders and orthodontics 3
(DoH) carried out a risk assessment concluding that all their movement through capillaries and hence deprives
recipients of UK sourced plasma-derived coagulation the tissues of oxygen and in conscious patients causes
factor concentrates used in the period 1980–2001 should intense pain. The disease is chronic and life expectancy is
be regarded as being at risk of developing variant shortened to about 45 years.29
Creutzfeldt-Jakob disease (vCJD) for public health Sickle cell trait is the term given to patients who
purposes.21 Risk assessments have been carried by both inherit one of the genes of sickle cell disease but without
the DoH and the World Federation of Haemophilia developing the recurrent symptoms. It is not benign and
which could not identify any person with haemophilia can also have symptoms due to co-morbidity and
who has developed vCJD.22,23 Moreover, they con- conditions that can lead to overheating, dehydration
cluded that routine dental treatment including minor and sickling.
oral surgery is unlikely to pose a cross-infection risk. Sickle cell anaemia is more common in people of
African origin where malaria is common but it also
occurs in people of Asian and West Indian descent.30
Orthodontic considerations in patients with bleeding disorders
Treatment ranges from NSAIDs for milder vaso-
occlusive crises to IV opioids.31 Acute chest crises are
N Orthodontic treatment is not contraindicated in patients with
treated with antibiotics and blood transfusions to reduce
bleeding disorders.24 A thorough history and close liaison with
the patient’s haematologist, oncologist or physician will help the percentage of HbS in the blood. The risks of blood
reduce the risk of problems occurring. transfusions have been discussed above. Tetracycline
may need to be given as an alternative to amoxicillin or
N Patients should be encouraged to maintain excellent,
flucloxacillin when the child develops multiple drug
atraumatic oral hygiene.25
sensitivity. Chemotherapy32 and bone marrow trans-
N If extractions or surgery cannot be avoided, the management of plants have also been advocated and these treatments
patients with haemophilia relies on careful surgical technique, come with their own list of orthodontic considerations.
including an attempt at primary wound closure and the
Oral manifestations of sickle cell disease include
following regimen to:
# increase Factor VIII production with 1-desamino-8-D-
enamel hypoplasia in the form of white spots on the
arginine vasopressin (DDAVP) tooth surface, dentinal hypomineralization, delayed
# replace missing Factor VIII with cryoprecipitate, Factor tooth eruption, pale lips and oral mucosa and glossitis.
VIII, fresh frozen plasma or purified forms of Factor Radiographic signs include osteoporosis and parallel
VIII trabeculae amidst teeth but not in edentulous areas.33
# antifibrinolytic therapy with transexamic acid or epsilon- Mandibular osteomyelitis in the absence of other
amino caproic acid (EACA)25 problems can occur due to the limited blood supply.
N Nerve-block anaesthetic injections are contra-indicated unless Vaso-occlusive crises can predispose the patient to pain
there is no better alternative and prophylaxis is provided to and paraesthesia of the inferior alveolar nerve and the
prevent the risk of a haematoma forming.26 lower lip.
N Chronic irritation from orthodontic appliances should be
avoided. Fixed appliances are preferable to removable
appliances as the latter can cause gingival irritation.27
N Self-ligating brackets are preferable to conventional brackets. Orthodontic considerations in patients with sickle cell anaemia
If conventional brackets are used, archwires should be secured
with elastomeric modules instead of wire ligatures.27 N Orthodontic treatment is not contra-indicated in sickle cell
patients, provided the patient has no or very mild
N Care is required when placing and removing archwires.1
complications and the oral hygiene is excellent.
N The duration of orthodontic treatment should be kept to a
N Intervention in these patients favours a multidisciplinary
minimum to reduce the potential for complications.28 approach involving the patient’s physician, haematologist,
dentist, and family.
Leukaemia is divided into acute and chronic forms. Dahlöf and Huggare have produced an excellent review on the risk
Acute lymphoblastic leukaemia (ALL) is the commonest factors to be aware of when planning orthodontic treatment in long-
presentation in children accounting for 25% of all term survivors of childhood malignancy.40
childhood tumours. The prognosis in children with Before diagnosis
ALL is better than that for adults for whom the long- N Significant orofacial complications of leukaemia in children
term survival is low. Acute myeloblastic leukaemia include lymphadenopathy, spontaneous gingival bleeding
(AML) is more common in adults than children and the caused by thrombocytopenia (reduction in platelets), labial and
prognosis is poor. The treatment for acute leukaemia lingual ecchymoses and mucosal petechiae, ulceration, gingival
includes chemotherapy or bone marrow transplantation swelling, and infections. The orthodontist may be the first to
notice signs of the illness.41 Patients presenting with
(BMT). Total body irradiation (TBI) and immunosup-
spontaneous bleeding in the presence of good oral hygiene
pression are used to prevent graft-versus-host disease
warrant an immediate referral to a physician.2
after BMT. After diagnosis
Chronic leukaemia involves the proliferation of more
mature cells than those found in acute leukaemia. The N Orthodontic treatment should be postponed if the patient
prognosis is better and adults are more commonly requires chemotherapy as the drugs can exacerbate the
thrombocytopenia and agranulocytosis.
affected than children. Chronic lymphocytic leukaemia
After treatment
(CLL) is more common and patients tend to be
asymptomatic. Chronic myeloid leukaemia (CML) N It has been suggested that orthodontic treatment should be
affects adults of a younger age group than CLL. The postponed until at least 2 years after BMT.2 By then the risk
main signs of the chronic leukaemia tend to be for relapse of the malignancy has diminished and the patient is
splenomegaly and lymph node enlargement. Treatment no longer on immunosuppressive therapy. Additionally, the
growth rate and the need for supplemental growth hormone
is with chemotherapy and radiotherapy.
have been assessed.
The sequelae of treatment may be immediate or may
occur several months after treatment. These effects can N In view of the fact that TBI can suppress growth, the prognosis
be caused by the malignancy itself, by the treatment for growth modification in skeletal Class II malocclusions is
including chemotherapy, radiotherapy and supportive guarded.40
care such as transfusions, antibiotics and immunosup- N The treatment should be modified to reflect the patient’s
pressive treatment. The degree to which an individual is medical condition and planned with the patient’s best interests
affected is related to the age at which the disease is in mind. There are no reports about any adverse effects of
diagnosed and treated and the type and intensity of the orthodontic treatment in these patients.42 Treatment mechanics
treatment. The growth rate generally declines in children should be aimed at minimising the risk of root resorption,
during treatment for leukaemia. Soon after treatment keeping the forces low and accepting a compromised treatment
result. There may be merit in treating the upper jaw only to
the normal growth rate is resumed and catch up growth
reduce the risk of undesirable events.40
is sometimes seen. Growth hormone therapy has the
6 Patel et al. Clinical Section JO December 2009
Respiratory system
Relevance of drugs in respiratory disorders
Respiratory disorders are common and the use of
intravenous (IV) sedation and general anaesthesia The chronic use of corticosteroid inhalers can lead
(GA) for elective procedures may be contraindicated. to localized lowered resistance to opportunistic infec-
The unwanted effects of prescribed drugs can also tions. As a result of this oro-pharyngeal candidal
influence the orthodontic treatment of these patients. infection may occur.52 To avoid this complication,
patients should be advised to rinse and gargle with
water after the use of their inhaler especially if wearing
Asthma
removable acrylic appliances.53 Candidiasis can be
Approximately 300 million people around the world treated with topical antifungal agents such as nyastatin.
have asthma, and it has become more common in both Additionally the regular use of inhaled corticosteroids
children and adults globally in recent years.45 The can predispose the patient to an adrenal crisis if
severity varies from mild to severe. In moderate cases subjected to stress. The need for steroid cover is
episodes are severe but the patients are symptom free discussed in the general section on drugs and orthodon-
between attacks. In severe asthma the attacks are severe tic treatment.
and the child is never asymptomatic and growth and Beta-adrenergic agonist bronchodilators such as sal-
lung function can be affected. butamol, antimuscarinic bronchodilators, cromogly-
There has been a tentative link between orthodonti- cates and antihistamines can all produce dry mouth,
cally induced external root resorption and patients with taste alteration and discolouration of teeth.
JO December 2009 Clinical Section Medical disorders and orthodontics 7
Epilepsy N Patients should be aware of and consented for the risk of soft
tissue and dental injuries as a result of a seizure.60
Epilepsy is a common symptom of an underlying N Gingival overgrowth associated with phenytoin is the most
neurological disorder. The seizures can take a variety widely known complication of anti-epileptic medication, with
of forms and epilepsy is considered to be active if a 50% of individuals being affected within 3 months of starting
person has had a seizure within the last 2 years or is the drug.61 Gingival hyperplasia is greater in those with high
taking anti-epileptic medication.56 plaque scores but there is also a genetic link.62 Gingivectomy is
Brain damage due to injury, infection, birth trauma or recommended to remove any hyperplastic tissue that interferes
a cerebrovascular accident accounts for 25% of cases. with appearance or function. For patients with recurrent
The other 75% of cases have no identifiable cause but hyperplasia, the patient’s physician should be contacted to
discuss alternative medication. Gingival hyperplasia resolves
there is a familial trend. Epilepsy can develop in some
spontaneously within 1–6 months of phenytoin
genetic syndromes such as Down’s syndrome57 or in
withdrawal.63
Sturge-Weber syndrome.58
8 Patel et al. Clinical Section JO December 2009
term damage to the eyes, kidneys, nerves, heart and in medical care resulting in reduced morbidity and
major arteries.74 mortality.76 The most common renal condition to
Oral complications include: xerostomia, burning present to the orthodontist is chronic renal failure
mouth and/or tongue, candidal infection, altered taste, (CRF).
progressive periodontal disease, dental caries, acetone CRF occurs after progressive renal damage.
breath, oral neuropathies, parotid enlargement, sialosis The symptoms and signs vary and can affect diverse
and delayed wound healing. These complications can body systems. Bone disease or renal osteodystrophy is
occur even when the blood glucose is well controlled due an almost universal feature of CRF. Calcium metabo-
to impaired neutrophil function but are all more severe lism is compromised by an elevated parathyroid
in uncontrolled DM. hormone and by disruption in vitamin D metabolism.
This results in secondary hyperparathyroidism. Renal
Orthodontic considerations in patients with DM disease also causes anaemia and marrow fibrosis leads to
a reduced platelet count and poor platelet function.
N Orthodontic treatment should be avoided in patients with Haemostasis is impaired to varying degrees in patients
poorly controlled DM as they are more likely to suffer from with CRF.
periodontal breakdown.27 Well-controlled DM is not a Initially treatment is conservative with dietary
contraindication for orthodontic treatment. restriction of sodium, potassium and protein. As the
N Rigorous preventative regimes should be put in place. The disease progresses dialysis or transplantation are
patient should be made aware of the consequences of poor oral required. Many patients are prescribed steroids to
hygiene and the increased risk of periodontal disease. either combat renal disease or to avoid transplant
rejection. Immunosuppressant drugs such as cyclospor-
N Early morning appointments are least likely to interfere with
ine and calcium channel antagonists such as nifedipine
the diabetes control regime. Patients should be advised to eat a
usual meal and take the medication as usual prior to longer
are also taken to prevent transplant rejection.
appointments. Immunosuppressants predispose the patients to infec-
tions. These drugs can also cause drug induced gingival
N Diabetic related microangiopathy can affect the peripheral
overgrowth as discussed in the section on drugs and
vascular supply, resulting in unexplained toothache, tenderness
orthodontic treatment.
to percussion and even loss of vitality.75 It has been suggested
that patients with DM should be treatment planned as
In children CRF leads to decreased growth and
periodontal patients. Light physiological forces should be used sometimes delayed eruption and enamel hypoplasia.
in all patients to avoid overloading the teeth.
progressing to coma if untreated. dialysis is imminent. If possible treatment could be carried out
Treatment in the orthodontic surgery75 prior to transplantation to avoid the risks associated with
immunosuppressant drugs.
N Conscious 50 g of glucose as a drink, tablet or gel
N Appointments should be scheduled on non-dialysis days. The
N Unconscious 20 ml of 50% Dextrose IV or 1 mg of glucagon day after dialysis is the optimum time for treatment for surgical
should be administered intramuscularly. procedures as platelet function will be optimal and the effect of
N When the patient is cooperative oral glucose should be given to heparin will have worn off.
prevent recurrent hypoglycaemia. If recovery is delayed, the N Surgical procedures are best carried out under local
emergency services should be called. anaesthetic. The anaemia and the potential electrolyte
disturbances that can predispose the patient to cardiac
arrhythmias can complicate general anaesthesia.
Renal disorders N Haemostasis is impaired as a result of platelet dysfunction
Impaired drug excretion leads to the need for care with drug
Patients with kidney disorders are presenting more
prescriptions.
frequently in orthodontic practice due to improvements
JO December 2009 Clinical Section Medical disorders and orthodontics 11
tablets by mouth should receive parenteral corticoster- The risk of side effects is greater if the dose is
oid cover during these periods.’104 administered intravenously and on a long-term basis.109
In contrast various authors have suggested modified Symptoms and signs of ONJ may include pain,
guidelines for the management of patients on steroid swelling, pus formation, paraesthesia, ulceration of soft
medications.105 These authors reported on a number of tissue, intra-oral or extra-oral sinus tracts, loose teeth
studies confirming the low likelihood of significant and exposed bone.110
adrenal insufficiency even following major surgical The pathogenesis of BP associated ONJ is not fully
procedures. Patients on long-term steroid medication known. One suggestion is that hypodynamic and
do not require supplementary ‘steroid cover’ for routine hypovascular bone is unable to meet an increased
dentistry, including minor surgical procedures, under demand for repair and remodelling due to physiological
LA. Instead the blood pressure should be monitored stress (mastication), iatrogenic trauma (tooth extrac-
throughout the procedure with IV hydrocortisone tion) or due to odontogenic infection. This can be
available in the event of a crisis.106 Patients undergoing exacerbated by the following factors:
GA for surgical procedures may require supplementary
steroids dependent upon the dose of steroid, duration of N corticosteroid treatment;
treatment and severity of the planned surgery.105 N chemotherapy;
The second factor to be aware of is that glucocorticoid
N medical co-morbidities such as diabetes mellitus;
therapy is known to affect bone turnover. Kalia and co-
N the presence of dental disease;111
workers studied the effect of acute and chronic N dental extractions;
corticosteroid treatment in rats.107 Their results indicate N oral bone surgery;
that bone turnover is reduced in subjects on acute N poorly fitted dental appliances;
corticosteroid treatment and increased in patients on N smoking;
chronic corticosteroid therapy. The authors postulated N alcohol abuse.
that it may be wise to postpone orthodontic treatment Radiographic signs include widening of the periodontal
on patients on acute doses. They also suggested that ligament space at the molar furcation areas and mottled
orthodontic forces should be reduced and checked more bone consistent with osteolysis.111
frequently in patients on chronic steroid treatment.
Orthodontic considerations in patients taking BPs
Bisphosphonates (BPs)
N Amend the medical history form to identify patients who are
These drugs are commonly prescribed to manage taking BPs.112
osteopenia and osteoporosis or to treat hypercalcaemia
caused by bone metastasis in cancer patients (see
N Orthodontic treatment can only be considered after discussion
with the patient’s physician and other medical specialists they
Table 2). About half of the BP that is resorbed is may be under the care of. Ascertain why the patient is on BPs.
excreted unchanged by the kidneys; the remainder has a Assess the risk of osteoradionecrosis via the route of
high affinity for bony tissues and a reported half-life of administration, duration of treatment, dose and frequency of
10 years. BPs inhibit the resorption of trabecular bone use.113
by osteoclasts and hence preserve bone density.
Although their medical benefits have been proven, there
N If possible treatment should be carried out prior to BP
treatment.
are increasing numbers of side effects that can affect
orthodontic treatment including delayed tooth eruption, N In patients at high risk of ONJ, it may be better to accept the
inhibited tooth movement,108 impaired bone healing, malocclusion and consider the benefits of cosmetic
dentistry.114
and BP-induced osteoradionecrosis (ONJ) of the jaws.
Oral bisphosphonates – osteoporosis, Pagets disease, osteogenesis Alendronate (Fosamax, Merck) 70 mg per week
imperfecta Risedronate (Actonel, Aventis) 35 mg per week
Ibandronate (Boniva, Roche) 2.5 mg per day
IV bisphosphonates – cancer Pamidronate (Aredia, Novartis) 90 mg per month
Zoledronate (Zometa, Novartis) 4 mg per month
14 Patel et al. Clinical Section JO December 2009
Orthodontic considerations in patients taking BPs Orthodontic considerations in patients with DIGO
z; pamidronate, 300 days; zoledronate, 146 h).115 patient, his or her physician, GDP, periodontist, hygienist and
the orthodontist.76 Early liaison with the patient’s physician is
N Patients on oral BPs are at a lower risk of ONJ or osteoclastic recommended to investigate whether an alternative drug can be
inhibition. Patients should be counselled about inhibited tooth prescribed.
movement, ONJ and impaired bone healing with elective
surgery procedures. If orthodontic treatment is indicated, it N Treatment should be aimed at reducing the risk of DIGO
occurring or at least preventing the DIGO worsening. The
should be planned to minimize risks including a non-extraction
protocol favouring interproximal stripping to limit the recurring message is to ensure patients have excellent oral
treatment time and the degree of tooth movement and so hygiene in order to reduce the risk of DIGO.117 A rigorous oral
hygiene programme should be instigated from the outset and
treatment can be discontinued early if needed. Informed
consent should outline all the risks associated with reinforced during treatment.
orthodontics and BPs.113 N A non-extraction approach is preferred in case treatment has to
N The clinician should look for signs of ONJ and the patient be terminated due to medical problems or exacerbation of the
DIGO.76 Additionally, space closing mechanics including
should be advised to have regular dental check-ups.
nickel titanium closing springs, elastomeric power chain or
N Some clinicians suggest that one should try to avoid invasive active ties can impinge on the hyperplastic gingival tissue.
laser therapy or temporary anchorage devices in treatment Archwire loops could have a similar effect and be displaced
plans;112 however a recent study of implants placed in 61, buccally, altering the direction of force.76
female patients taking oral BPs for longer than 3 years,
revealed no untoward postoperative sequelae. This suggests N Small low profile brackets are recommended and the excess
composite around the margins should be removed. Bands
that patients who take oral BPs are no more at risk of implant
or temporary anchorage device failure than other patients. should be avoided if possible as they have been associated with
significantly more gingival inflammation than bonded
molars.119
Figure 1 Anaphylaxis treatment algorithm – adapted from Resuscitation Council UK guidelines 2008
Nickel fluids, certain foods and fluoride media can corrode and
accelerate the leaching process.126 Concerns about
Orthodontists are sometimes required to treat patients sensitising orthodontic patients to nickel are not
with an allergy to nickel and nickel is present in a supported by the literature but there are a few case
number of orthodontic materials, notably nickel tita- reports of localized allergic responses attributed to
nium (Ni–Ti) archwires. The nickel in stainless steel (SS) nickel containing orthodontic appliances.127,128
is thought to be tightly bound to the crystal lattice of the Oral clinical signs and symptoms of nickel allergy can
alloy making it difficult for it to leach out. include the following: a burning sensation, gingival
The immune response to nickel is usually a type IV cell hyperplasia, angular chelitis, labial desquamation,
mediated delayed hypersensitivity reaction. The first erythema multiforme, periodontitis, stomatitis with mild
phase or sensitization to nickel is increasing with the to severe erythema, loss of taste or metallic taste,
increasing use of jewellery containing the metal. The numbness, soreness of the side of the tongue.128
prevalence of nickel allergy is estimated 11% of all
women and 2% of men.122 Re-exposure to nickel can
results in contact dermatitis or mucositis and develops
over a period of days or rarely up to 3 weeks.123
Fortunately most individuals with nickel allergy do not Orthodontic considerations in patients with a nickel allergy
report reactions to orthodontic appliances containing
nickel. A study by Bass and colleagues of 29 subjects (18
female and 11 male) revealed an initial positive skin
N A dermatologist should confirm a true nickel allergy.
patch test to nickel sulphate in five female patients N Patients with a defined history of atopic dermatitis to nickel
only.124 All 29 patients were followed over their fixed containing metals should be treated with caution and closely
appliance treatment. None of the subjects including the monitored during orthodontic treatment.129
positive test patients demonstrated an inflammatory N In patients with diagnosed nickel hypersensitivity and where
reaction or discomfort as a result of orthodontic intra-oral signs and symptoms are present the orthodontist
treatment. It is postulated that a much greater should replace Ni-Ti archwires with one of the following:
concentration of nickel in the oral mucosa than the # stainless steel archwires with a low nickel content;
skin is necessary to elicit an immune response. Nickel # titanium molybdenum alloy (TMA) which is nickel
free;
leaching from orthodontic bands, brackets, stainless
# fibre reinforced composite wires;
steel or Ni–Ti archwires has been shown in vitro to occur
# pure titanium or gold plated wires.
within the first week and then decline thereafter.125 Oral
16 Patel et al. Clinical Section JO December 2009
Orthodontic considerations in patients with a nickel allergy Orthodontic considerations in patients with latex allergy
N If the allergic reaction continues, all SS archwires and brackets N The goal is to significantly reduce exposure to patients
should be removed. If the allergic reaction is severe the patient routinely. This can be done by cleaning the surgery more
should be referred to a physician. Alternative nickel free frequently with a protein wash, cleaning or changing the air
bracket materials include ceramic, polycarbonate, titanium and filter more regularly.132
gold.129 Fixed appliances may be substituted with plastic
aligners in selected cases.
N Latex free goods should be stored in a ‘latex-screened’ area to
avoid prior contamination with latex products.
Patients with eating disorders rarely present with endocarditis of the European society of cardiology. Eur
problems of compliance. Oral manifestations of eating Heart J 2004; 25: 267–76.
disorders include dental caries, erosion, dentinal hyper- 6. Danchin N, Duval X, Leport C. Prophylaxis of infective
sensitivity, salivary gland hypertrophy, raised occlusal endocarditis: French recommendations 2002. Heart 2005;
restorations and xerostomia.136 91: 715–18.
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Chemotherapy. J Antimicrob Chemother 2006; 57: 1035–
N The orthodontist is likely to notice these features and should be 42.
suspicious of these illnesses and deal with them sensitively.137 8. Wilson W, Taubert KA, Gewitz M, et al. Prevention of
The first referral should be to the patient’s physician. However, infective endocarditis: guidelines from the American Heart
it is important to maintain confidentiality and gain consent.138 Association: a guideline from the American Heart
Referral to another healthcare professional, such as a physician Association Rheumatic Fever, Endocarditis and
may be a breach of confidentiality if the patient did not give
Kawasaki Disease Committee, Council on
their consent. These patients are less likely to discuss their
Cardiovascular Disease in the Young, and the Council
illness as they tend to be embarrassed and secretive.
on Clinical Cardiology, Council on Cardiovascular
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alternative to normal food.139 Am Dent Assoc. 2008; 139(Suppl): 3S–24S.
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