5th Year Lec. No.

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Orthodontic care of medically compromised patients

As medical science continues to make advances that increase the quantity and
quality of life with previously untreatable diseases, dental practitioners are
seeing more and more of these patients for routine care.  Thus, orthodontists
need to be aware of the possible clinical implications of these diseases. He
must have a basic working knowledge of patient's disease process and should
inform the general physician about the type of procedures
planned. Treatment plan should be modified according to impact of the
particular disease in the oral cavity. This article examines aspects of some of
the conditions that are of relevance to orthodontic practice. Medical
conditions commonly encounter in orthodontic patients include;

1- Infective Endocarditis

Bacterial endocarditis is a relatively uncommon, life-threatening infection of

the endothelial surface of the heart, including the heart valves. The infection
usually develops in individuals with underlying structural cardiac defects. It
can occur whenever these persons develop bacteremia with the organisms
likely to cause endocarditis. Both the incidence and the magnitude of
bacteremia's of oral origin are proportional to the degree of oral
inflammation and infection.

Orthodontic considerations

Orthodontist should communicate with the patient's physician to confirm

the risk of IE. Informed consent requires that a patient is aware of any
significantly increased risk.

The importance of maintaining an exemplary standard of oral hygiene and

that it is their responsibility to protect themselves.

The main orthodontic procedure that has been postulated to cause a

bacteremia has been placement of a separator.

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Orthodontics should avoid using orthodontics bands instead use, bonded

attachments. If banding is required use of antibiotic prophylaxis is must.

Antibiotic prophylaxis is only required in high-risk patients and the drug of

choice is penicillin.

2- Hemophilia
Hemophilia is the most common congenital bleeding disorder. Hemophilia
A is a sex-linked disorder due to a deficiency of clotting factor VIII. Other
bleeding disorders include hemophilia B or Christmas disease (factor IX
deficiency) and von Will brand's disease (defects of von Will brand's factor).
The normal concentrations of clotting factor are between 50% and 150% of
average value and the minimum level of a factor for adequate hemostasis is
25%.

Orthodontic considerations

Orthodontic treatment is not contraindicated in patients with bleeding

disorders.

Duration of treatment should be given careful consideration. Lengthier the

treatment duration may increase potential complications.

Chronic irritation from orthodontic appliances should be avoided. Fixed

appliances are preferable to removable appliances as the latter can cause
gingival irritation.

Self-ligating brackets are preferable to conventional brackets. If

conventional brackets are used, arch wires should be secured with
elastomeric modules instead of wire ligatures.

If extractions or surgery is to be performed increase factor VIII production

with 1-desamino-8-darginine vasopressin (DDAVP). Parenteral DDAVP can
be used to raise factor VIII levels 2-3-fold to prevent surgical hemorrhage.

3- Hematological Malignancies

More than 40% pediatric malignancies are hematological either leukemia or

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lymphoma. Cranial irradiation given to children with acute lymphocytic

leukemia (ALL) to eliminate cancer cells in the central nervous system (CNS)
can cause growth retardation, most probably through its effect on pituitary
function, specifically growth hormone deficiency. Adults treated for childhood
cancer have been shown to have a reduced bone mineral density. Arrested
root development with short V-shaped roots and premature apical closure has
been reported after cancer therapy.

Orthodontic considerations

In these patients intense chemotherapy weakens regenerative capacity of

mucosa. Minor irritation can lead to opportunistic infection and subsequent
severe complications.

Use appliances that minimize the risk of root resorption, Use lighter forces,
terminate the treatment earlier than normal, choose the simplest method
for the treatment needs and do not treat the lower jaw. The lower jaw is at
risk of osteoradionecrosis (ORN) because of its limited blood supply.

Orthodontic treatment may start or resume after completion of all medical

therapy and after at least 2-year event free survival when risk of relapse
has been decreased. In adults receiving head and neck radiotherapy the
incidence of ORN is 8.2%.

4- Thalassemia
Thalassemia is an inherited disorder of hemoglobin synthesis. It can be can be
classified as α-thalassemia, β-thalassemia, γ-thalassemia and δ-thalassemia
indicating which blood hemoglobin chains are affected. Based on their clinical
and genetic orders they are classified into major (homozygous) and minor
(heterozygous) types. β-Thalassemia major (Cooley's anemia) is the most
severe form of congenital hemolytic anemia. The most common oral and facial
manifestation is enlargement of the maxilla, bossing of the skull and
prominent malar eminences due to the intense compensatory hyperplasia of
the maxilla. This lead to expansion of the marrow cavity and a facial
appearance known as "chipmunk" face. the overdevelopment of the maxilla
frequently result in an increased over jet and spacing of maxilla teeth and
other degree of malocclusion.

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Orthodontic consideration

Patient who have undergo splenectomy are at massive risk of infection

followed by bacteremia. Antibiotic prophylaxis must be given during invasive
procedures like extraction. Antibiotic of choice is penicillin V 2000 mg or
erythromycin 1000 mg taken 30 min to 2 h prior to dental procedure, then 500
mg taken every 6 h for 8 doses.

Functional and extra-oral appliances can be used; however, the "skeletal

forces" in thalassemia patients must be less than what is used with normal
patients because of the thin cortical plates in thalassemia patients.

Radiographs at 3 months intervals can be indispensable because the thin

cortical plates can complicate orthodontic treatment.

Regular prophylaxis and fluoride applications are recommended in these

patients.

Extraction should be carried out at the time of admission for blood

transfusion, i.e. when hemoglobin level is at its highest, with the
administration of antibiotics.

Thalassemia patients are at an increased risk of viral hepatitis and AIDS due
to repeated blood transfusion and therefore screening test for the same
should be carried out at regular intervals.

5-Bronchial Asthma

Asthma is a chronic disease that affects the lower airways. It is characterized

by recurrent and reversible airflow limitation due to an underlying
inflammatory process. Signs and symptoms of asthma, include intermittent
wheezing, coughing, dyspnea, and chest tightness.

Orthodontics considerations
Inhaled corticosteroids are the most widely used and most effective asthma
anti-inflammatory agents.

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Oral manifestations include candidiasis, decreased salivary flow, increased

calculus, increased gingivitis, and increased periodontal disease.

Schedule these patients' appointments for late morning or later in the day,
to minimize the risk of an asthmatic attack.

Judicious use of rubber dams should be avoided as they reduced breathing

capability.

Care should be used in the positioning of suction tips as they may elicit a
cough reflex.

Up to 10% of adult asthmatic patients have an allergy to aspirin and other

non steroidal anti-inflammatory agents. A careful history concerning the
use of these types of drugs needs to be elicited. The orthodontist should
ensure the patient has their inhaler nearby.

6- Epilepsy
Epilepsy is the most common serious chronic neurological condition. It is as a
chronic neurological disorder characterized by frequently recurrent
seizures. The risk of developing epilepsy is 2-5% over a lifetime. It affects
about 0.5-2% of the population. Injuries to the tongue, buccal mucosa, facial
fractures, avulsion, luxation or fractures of teeth and subluxation of the
temporomandibular joint can occur during seizures. Both the condition and
the medical management of condition can affect oral health.

Orthodontic considerations
The orthodontist should ensure the patient is receiving regular and rigorous
preventative dental care to avoid/minimize dental disease.

Gingival overgrowth associated with phenytoin is the most widely known

complication of anti-epileptic medication. Gingivectomy is recommended to
remove any hyperplasic tissue that interferes with appearance or function.

Removable appliances should be used with caution as they can be dislodged

during a seizure.

Wherever possible removable appliances should be designed for maximum

retention and made of high impact acrylic.

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The metal in a fixed orthodontic appliance may distort images obtained by

magnetic resonance imaging (MRI). An acceptable MRI may be obtained if
arch wires and other removable components are removed before the scan.

7- Diabetes Mellitus
DM is one of the most common endocrine disorders. It is characterized by
persistently raised blood glucose levels (hyperglycemia), resulting from
deficiencies in insulin secretion, insulin action, or both. Diabetes can be Type 1
(insulin dependent diabetes mellitus or juvenile onset diabetes) results from
defects in insulin secretion or Type 2 (non-insulin dependent diabetes mellitus
or mature-onset diabetes) develops as a result of defects in insulin secretion,
insulin action or both.

Orthodontic considerations
The key to any orthodontic treatment for a patient with diabetes is good
medical control. Orthodontic treatment should not be performed in a patient
with uncontrolled diabetes.

Importance should be given to maintain good oral hygiene, especially when

fixed appliances are used. Diabetic related microangiopathy can affect the
peripheral vascular supply, resulting in unexplained toothache, tenderness
to percussion and even loss of vitality.

Apply light forces and not to overload the teeth. Uncontrolled or poorly
controlled diabetic patients have an increased tendency for periodontal
breakdown and these patients should be considered in the orthodontic
treatment plan, as periodontal patients.

8- Renal Disorders
The most common renal condition to present to the orthodontist is chronic
renal failure. Chronic renal failure is a progressive and irreversible decline in
renal function. the number of functional units of the kidney or nephrons
diminishes, the glomerular filtration rate falls, while serum levels of urea
rise. Up to 90% of patients with renal insufficiency show oral signs and
symptoms in soft and hard tissues, some of them being a cause of the disease
itself and others deriving from the treatment. Initially treatment is
conservative with dietary restriction of sodium, potassium and protein. As the

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disease progresses dialysis or transplantation are required. Many patients are

prescribed steroids to either combat renal disease or to avoid transplant
rejection

Orthodontic considerations

Extraction should be done cautiously in such patients. Abnormal bone healing

after extraction can result due to alterations in calcium and phosphors
metabolism and secondary hyperparathyroidism which result in bone
demineralization.

Due to the increase in circulating parathyroid hormone. It has been

suggested that orthodontic treatment forces should be reduced and the
forces re-adjusted at shorter intervals.

Renal insufficiency is considered a risk condition for IE if the patient does

not have a good control of the disease. Antibiotic prophylaxis should be
consider in hemodialyzed patients who were undergoing an invasive dental
procedure.

During hemodialysis, the patient's blood is anticoagulated with heparin to

facilitate blood transit. For this reason, dental treatments with a risk of
bleeding must not be performed on the day of hemodialysis. Appointments
should be scheduled on non-dialysis days. The day after dialysis is the
optimum time for treatment for surgical procedures as platelet function will
be optimal and the effect of heparin will have worn off.

Many antibiotics are actively removed by the kidney, so adjustment of the

dosage by amount or by frequency is required. Penicillin and its derivates
are the preferred antibiotics for these patients. In the case of non-narcotic
analgesics, paracetamol is the best choice.

In renal transplant patients corticosteroid are given to minimize the risk of

transplant failure. In such patients to minimize the risk of adrenal crisis in
patients during surgical procedure, double the dose of corticosteroids on
the day of the surgery.

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Gingival overgrowth secondary to the immunosuppressive therapy is the

most studied oral manifestation. Nifedipine increases the prevalence of
gingival overgrowth. Gingival overgrowth can impede tooth movement
during orthodontic treatment. Gingivectomy should be considered in such
patients.

9- Osteoporosis
Osteoporosis is chronic, systemic, degenerative disease characterized by
decreased bone mass, a micro architectural deterioration of the bone and
consequent increase in bone fragility. Risk factors that cannot be altered
include advanced age, being female, estrogen deficiency after
menopause. Potentially modifiable risk factors include excessive alcohol
intake, vitamin D deficiency, and smoking. Drugs most commonly used in
treatment of osteoporosis are bisphosphonate (BP), estrogen, and calcitonin's.

Orthodontic considerations

Orthodontic treatment therefore, must include the consideration of problems

such as bone loss, retention instability, and temporomandibular dysfunction.

Problem associated with medication must also be given consideration.

Estrogen decreases the rate of tooth movement. However, if these drugs
are not used during orthodontic treatment in patients with osteoporosis,
resorption of alveolar bone and possibly tooth roots could occur.

Use of BP can affect orthodontic treatment by delaying tooth eruption,

inhibited tooth movement, impaired bone healing, and by causing BP-
induced (ORN) of the jaws.

Extraction protocol and use of temporary anchorage devices should be

avoided.

BP inhibits osteoclasts, decreases microcirculation and thus impedes tooth

movement.

10- Thyroid and Parathyroid Disorders

After DM, thyroid disease is the most common endocrine problem. Thyroid

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diseases occur more often in women and most often in women older than 50
years of age.

Orthodontic considerations

Orthodontic therapy requires minimal alterations in the patient with

adequately managed thyroid disease.

In hyperthyroidism enlarged tongue may pose problem during treatment.

The bone turnover can influence orthodontic treatment. High bone

turnover (i.e., hyperthyroidism) can increase the amount of tooth
movement compared with the normal or low bone turnover state in adult
patients.

Low bone turnover (i.e., hypothyroidism) can result more root resorption,
suggesting that in subjects where a decreased bone turnover rate is
expected, the risk of root resorption could be increased.

11- Liver Diseases

Liver diseases are very common and can be classified as acute (characterized
by rapid resolution and complete restitution of organ structure and function
once the underlying cause has been eliminated) or chronic (characterized by
persistent damage, with progressively impaired organ function secondary to
the increase in liver cell damage). Liver disease can result from acute or chronic
damage to the liver, usually caused by infection (hepatitis A, B, C, D, and E
viruses, infectious mononucleosis), injury, exposure to drugs or toxic
compounds, an autoimmune process, or by a genetic defect. The liver has a
broad range of functions in maintaining homeostasis and health: it synthesizes
most essential serum proteins (albumin, transporter proteins, blood
coagulation factors V, VII, IX and X, prothrombin, and fibrinogen. Liver
dysfunction alters the metabolism of carbohydrates, lipids, proteins, drugs,
bilirubin, and hormones.

Orthodontic considerations

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Hepatitis B is a worldwide health problem, with an estimated 400 million

carriers of the virus. It has been calculated that 1.53% of all patients
reporting to the dental clinic are hepatitis B virus (HBV) carriers. Viral
hepatitis is surely of importance to the orthodontist. HBV, hepatitis C virus,
and hepatitis D virus are blood borne and can be transmitted via
contaminated sharps and droplet infection.

Aerosols generated by dental hand pieces could infect skin, oral mucous
membrane, eyes or respiratory passages of dental personnel. The main
orthodontic procedures to result in aerosol generation are removal of
enamel during interproximal stripping, removal of residual cement after
debonding, and prophylaxis.

Infection control protocol should be followed according to the guideline laid

down by occupational safety and health administration. All members of
the team should be immunized against HBV. Barrier technique such as
gloves, eye glasses, and mouth mask should be used.

HBV can survive on innate subjects for 7 days. Impressions can be one of
the links in transmitting the HBV to orthodontics. The impressions must be
disinfected by dipping them in glut aldehyde or by spraying sodium
hypochlorite and leaving it for 10 min.

Post-exposure prophylaxis for HBV infection should be given to those who

are exposed percutaneously or through mucus membrane to blood or body
fluids of known or suspected.

Liver disease can result in depressed plasma levels of coagulation factors. If

extraction is required, special attention should be paid as the risk of
bleeding increases; an infusion of fresh frozen plasma may be indicated.
Advanced oral surgical procedures or any dental procedures with the
potential to cause bleeding performed on a patient with multiple or a
severe single coagulopathy may need to be provided in a hospital setting.

Care should be taken when prescribing any medication for patients with
liver disease. Hepatic impairment can lead to failure of metabolism of some
drugs and result in toxicity. Caution should be used in prescribing

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medications metabolized in the liver, such as acetaminophen, nonsteroidal

anti-inflammatory agents.

12-Down Syndrome
Down syndrome is one of the most common genetic syndromes, occurring in
one of 800-1000 live births. ohn Langdon Down who published an accurate
description of a person with Down syndrome discovered Down syndrome in
1866, although he did not know the cause of the syndrome. He was then
termed the "father" of the syndrome.

The primary skeletal abnormality affecting the orofacial structures in Down

syndrome is an underdevelopment of the midfacial region. The bridge of the
nose, bones of the midface and maxilla are relatively smaller in size. In many
instances this causes a prognathic class III occlusal relationship, which
contributes to an open bite. Individuals with Down syndrome have delayed
eruption pattern. There is usually some sort of enamel defect affecting the
teeth. There is usually congenitally missing teeth and they can have unusually
shaped teeth.

Orthodontic considerations
Congenital heart defects are present in 40-60% of infants with Down
syndrome. Children with heart defects who are undergoing dental
procedures should be given antibiotic prophylaxis against subacute
bacterial endocarditis.

Reduced muscle tone causes less efficient chewing and natural cleansing of
the teeth. More food may remain on the teeth after eating due to this
inefficient chewing. hence oral hygiene instruction should be given in every
visit.

It is ensure that patient is vaccinated for hepatitis before starting dental

treatment. This is necessary because persons with Down syndrome are at
increased risk of developing the carrier state if they are infected with HBV.

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Seizures occur in 5-10% of children with Down syndrome. Generalized tonic

clonic seizures are the most common. Seizures are diagnosed and treated
similarly in children with and children without Down syndrome.

Impressions using quick-set materials with fun flavors should be used as

these may reduce the tendency for activation of the more sensitive gag
reflex frequently experienced with Down syndrome patients.

High-memory wires allow a longer activation interval between

appointments.

Self-ligating brackets allow a more patient-friendly activation appointment.

13- Autism

Autistic disorder is a pervasive developmental disorder defined behaviorally as

a syndrome consisting of abnormal development of social skills (withdrawal,
lack of interest in peers), limitations in the use of interactive language (speech
as well as nonverbal communication), and sensorimotor deficits (inconsistent
responses to environmental stimuli. The typical presenting symptoms of
autistic disorder are delayed speech or challenging behavior before 3 years of
age. Indications for formal developmental evaluation include no babbling,
pointing, or other gestures by 12 months of age, no single words by 16 months
of age, no two-word spontaneous phrases by 24 months of age, and loss of
previously learned language or social skills at any age. The reported incidence
of autistic disorder ranges from about 5 per 10,000 to 20 per 10,000
persons. No single cause has been identified for the development of autism.
Genetic origins are suggested by studies of twins and a higher incidence of
recurrence among siblings. Some reports have suggested a possible association
with Down syndrome. In addition to the implication of neuro-transmitters,
such as serotonin, in the development and expression of autism. While use of
behavior modification programs is often the primary method of managing
challenging behaviors in autistic children, supportive medication use has been
found to help reduce behavior problems.

Orthodontic consideration
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The main challenge to the orthodontic team may be the reduced ability of
autistic patients to communicate and relate to others.

The first several visits are directed towards raising the patient's confidence
and determining the maximum level of compliance that is achievable.

At the same time, an estimate of the most suitable way (behavior

management, sedation or general anesthesia (GA)) to perform the more
difficult procedures, such as impressions or bracket bonding may be made.

The spectrum of methods used for pain and anxiety control during
orthodontic treatment of the autistic child may be divided into conscious
methods (such as oral, intramuscular, inhalation with nitrous oxide and
oxygen, and intravenous sedation) and unconscious methods which include
intravenous or inhalation deep sedation and GA with endotracheal
intubation.

Jackson was the first to suggest using GA for the placement of orthodontic
bands.

Patient should be treated in a quiet, shielded single operatory versus an

open-bay arrangement, with reduced decoration and dimmed lights.

Procedures such as tell-show-do, voice control, and positive reinforcement

are effective with children.

The effectiveness of reinforcers can vary among children with autism

spectrum disorder (ASD).Many children may find reinforcing value in
typical, age-appropriate reinforcers such as praise, stickers or video clips
while other children's behavior might be reinforced by engaging in self-
stimulatory behaviors (for example, hand flapping, or self-talk) or obsession
with unusual objects Hung DW. Using self-stimulation as reinforcement for
autistic children.

14- Tuberculosis
TB is a chronic infectious disease that is worldwide in distribution. TB
continues to occur in epidemic proportions and is estimated by the World
Health Organization to infect approximately nine million people annually. TB

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primarily affects the lungs but is also capable of involving almost any site in the
body including the oral cavity. In dentistry, the incidence of exposure to an
active TB patient is quite low. Oral lesions of TB are uncommon, with most
cases appearing as a chronic painless ulcer.

Orthodontic considerations

Patients with a medical history or symptoms indicative of undiagnosed active

TB should be referred promptly for medical evaluation to determine possible
infectiousness.

Elective dental treatment including orthodontics treatment should be

deferred until a physician confirms that a patient does not have infectious
TB.

TB is not a common occurrence in orthodontic offices but the orthodontic

team should be aware of its potential and the issues now associated with
the occurrence of active TB in patients who have immune disorders,
particularly those with human immunodeficiency virus (HIV) or acquired
immunodeficiency syndrome (AIDS).

The challenge to orthodontics is to be prepared for all infectious diseases

that may affect the practice.

15-Acquired Immunodeficiency Syndrome

AIDS is an infectious disease caused by the HIV, and is characterized by
profound immunosuppression that leads to opportunistic infections,
secondary neoplasm and neurologic manifestations. Oral manifestations are
common and may represent early clinical signs of the disease, often preceding
systemic manifestations. This aspect is particularly important as dentists may
be responsible for early detection of oral lesions which may indicate HIV
infection.

Orthodontic considerations
HIV infection does not necessitate changes in the orthodontic treatment
plan for a child or adolescent. However, effects of HIV infection on the

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pediatric patient and the patient's family may alter the clinician's approach
to treatment.

Many antiretoviral medications (ARV) can cause nausea and vomiting.

Frequent episodes of vomiting can affect the oral cavity by increasing acid
levels in the saliva and soft tissues. As a result, the oral flora may change
due to the overgrowth of bacteria that are not susceptible to acid. This
overgrowth can lead to oral conditions such as candidiasis and an increased
rate of dental caries. Therefore, it is critical that the oral hygiene and health
of children and adolescents receiving ARV medications be attended to daily.

Percutaneous injuries and blood splashes to the eyes, nose or mouth occur
frequently during orthodontic treatment. On average, dentists in Canada
report 3 percutaneous injuries and 1.5 mucous-membrane exposures per
year. The highest frequencies of percutaneous injuries were reported by
orthodontists (4.9 per year) and the highest frequencies of blood splashes
to the eyes, nose or mouth were reported by oral surgeons (1.8 per year).

Universal infection control procedures should be employed for all patients

irrespective of their health status.

The potential for allergic reactions and drug resistance increases over time
with increased usage and may increase with decreased immune function;
therefore, the judicious use of antibiotics is warranted.

During the visits the patient must be stimulated to recognize their

fundamental importance in maintaining oral health. Patients must also be
stimulated to use additional auxiliary procedures such as antiseptic
mouthwashes.

Xerostomia has been observed in pediatric patients. Clinicians should

recommend sugarless gum and frequent consumption of water or highly
diluted fruit juices to alleviate xerostomia.

Post-exposure prophylaxis (PEP) should be given immediately after the

accidental occurrence. PEP for HIV exposure is best when started within
golden period of < 2 h and there is little benefit after 72 h. The prophylaxis
needs to be continued for 28 days. PEP is available as either basic regimen
(2 nucleoside reverse transcriptase inhibitor (NRTI)) or expanded regimen (2
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NRTI and 1 Protease inhibitors (PI) drugs). NACO recommend

zidovudine/stavudine + lamivudine (basic regimen) and zidovudine +
lamivudine + lopinavir/ritonavir

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