A r t ic l e s

Guidelines are discussed for treating the

increasing number of special patients
seeking orthodontic care.

Orthodontic care for m edically

compromised patients: possibilities and
lim itations

John R. van Venrooy, DMD

William R. Proffit, DDS, PhD

I —l ong-term survival of adults with seri­

ous medical problems has become com­
monplace in recent decades, and the same
phenomenon is seen now increasingly in Fig 1 ■ Protocol for medically compromised orthodontic patients.
children with a history of congenital Identification From m edical history or clinical
heart disease; hemophilia, in chronic re­ evaluation
Consultation W ith patient’s physician, review
mission from childhood malignancies; or m edical prognosis, and current
with a variety of other serious but medi­ drug therapy
cally treatable conditions. Dental care is O rthodontic treatm ent Risk-benefit ratio m ust be
plan (? m odified) considered carefully; lim it invasive
an important part of health maintenance procedures and duration
for these patients. In certain circum­ O rthodontic therapy Special precautions: sterilization,
stances, orthodontic treatment may be avoidance of tissue irritation, and
periodontal m onitoring
prescribed for these patients, but little or
no information about orthodontic pos­
sibilities and limitations can be found in
the current literature. This paper is an
attempt to provide guidelines for ortho­
dontic evaluation and treatment of indi­ ever, that correction of disfiguring dental though comprehensive treatment is less
viduals with several different medical problems contributes in an important likely to be indicated for chronically ill
diagnoses. A general protocol for han­ way to an individual’s self-esteem and adults, they may benefit from adjunctive
dling medically compromised orthodon­ affects social integration and inter­ orthodontics that facilitates periodontal
tic patients is illustrated in Figure 1. action.1,2 If a child’s social adjustment is or restorative treatment (or both).
already complicated by a serious medical To evaluate the risks of orthodontic
Principles condition, denial of orthodontic treat­ treatment it is convenient to divide treat­
ment is not helpful from a broad health ment procedures into two groups; inva­
Orthodontic treatment is an elective pro­ perspective. Appropriate and com­ sive procedures that produce bleeding
cedure for essentially all patients, and prehensive orthodontic treatment for and transient bacteremia, that include
certainly for those with chronic medical such children can lead to a significant tooth extractions, surgical manipulation
problems. There is clear evidence, how­ improvement in overall well-being. Al­ of periodontal tissues, such as exposure

262 ■ JA D A , Vol. I l l , A ugust 1985


of unerupted teeth, placement of ortho­
dontic bands with subgingival extension,
and orthognathic surgery; and noninva-
sive procedures that have little or no risk
of bleeding complications, such as dental
impressions, placement of direct-bonded
fixed appliances, routine fixed appliance
adjustments, and insertion and adjust­
ment of most removable appliances. Cer­
tainly, any intraoral use of dental instru­
ments or materials provides the potential
for a laceration or puncture wound and so
may inadvertently become invasive, but,
for the most part, orthodontic appliance
therapy is noninvasive and can be used
even for medically compromised pa­
tients. Modifications in the therapeutic
approach to make all aspects of orthodon­
tic treatment as noninvasive as possible
are an essential step in planning therapy
for medically compromised individuals.
Orthodontic treatment is based on two
major biologic responses: pressure-
induced remodeling of the alveolar bone
so that teeth gradually move to a new
position; and alterations in growth pro­
duced by pressure or tension against the
jaws, or by repositioning of the mandible.
Growth changes, of course, are important
only in children. Tooth movement, al­
though somewhat slower in adults, can be
induced at any age. Both of these re­
sponses can be affected by illness, and
orthodontic treatment therefore is contra­
indicated during the acute or active phase
of any disease process. For patients with
adequate medical management, both the
dentoalveolar and growth responses tend
to be normal, with some possible excep­
tions under specific conditions. The
normal tissue responses of individuals
who have chronic but well-controlled
m edical problems allow orthodontic
treatm ent for most m ed ically com ­
promised patients.
In the following sections, specific med­
ical problems and associated special or­
thodontic considerations are discussed,
with emphasis on the modification of
treatm ent plans and procedures to
m inimize risks and complications.
Children with bleeding disorders,
sickle cell anemia, or
treated leukemia
If and how to provide orthodontic care for
a child with a blood dyscrasia can be a
difficult decision. Because of the increas­
ing number of children with long-term
survival with these conditions, however,
that decision must be addressed by many
practitioners. Life expectancy, the pres­
ence and severity of a bleeding diathesis,
reduced resistance to infection, and the
possibility of soft tissue breakdown are all
factors to be considered in the decision to
provide orthodontic care for these pa­
tients. Because many of the consid­
ART I CLE S
erations for orthodontic treatment are theplacement therapy can be provided.
same for bleeding disorders, sickle cell Chronic irritation, as from a removable
anemia, and leukemia in remission, they appliance, also may cause bleeding.
will be reviewed together. Functional appliances that reposition the
mandible may produce bleeding both
Bleeding disorders intraorally from tissue irritation and
w ithin the temporomandibular joints,
In addition to the classic inherited sex- making this sort of therapy less desirable
linked form of hemophilia, which affects for these patients than might be thought.
about one in 10,000 males, a number of Properly managed fixed appliances are
The norm al tissue responses o f individuals who have
chronic hut well-controlled m edical problem s allow
orthodontic treatment fo r most m edically
compromised patients.
other types of hemophilia caused by de­ less likely to provoke mucosal bleeding
ficiencies of the various clotting factors than removable ones. For a child with a
have been recognized.3 Because the prev­ bleeding disorder and a Class II maloc­
alence of malocclusion in these children clusion, extraoral force to a fixed appli­
is as high or higher than in other seg­ ance probably is a better choice than a
ments of the population, and long-term removable functional appliance. The
survival is highly probable, the child or longer the duration of treatment for any
parent often requests orthodontic consul­ patient with a bleeding disorder, the
tation. These children require special greater the potential for complications.
consideration from two points of view. For this reason, orthognathic surgery to
— Patients with hem ophilia usually correct a severe jaw discrepancy may be a
have received multiple transfusions of better choice for a hemophiliac patient
blood and blood products, which leads to than the apparently more conservative
a greatly increased incidence of hepatitis. but prolonged orthodontic growth-
They should be considered carriers for modification approach. As with any inva­
hepatitis until proved otherwise. A vari­ sive procedure, orthognathic surgery re­
ety of seriologic markers such as hepatitis quires preparation of the patient with
B surface antigen, core antigen, and E transfusion to replace the missing clot­
antigen identify patients who pose a clear ting factors,5'7 but with proper precau­
risk of disease transmission. In the dental tions, this surgery is entirely feasible.8
office, special precautions should be
taken in handling these patients to pre­
vent the possible spread of hepatitis virus Sickle cell syndromes
to the dentist, staff members, or other pa­
tients. These precautions include mea­ Sickle cell syndromes are the result of the
sures that prevent exposure to serum or presence of an abnormal form of hemo­
saliva such as the use of protective globin, hemoglobin S, in red blood cells.
eyewear, gloves, face masks, and auto­ These syndromes are inherited in a
clave or formaldehyde vapor pressure heterozygous form, sickle cell trait, and a
sterilization of all instruments, including homozygous form, sickle cell anemia.
orth odontic pliers that m ay not be Approximately 8% of black Americans
routinely subjected to this sort of steril­ have sickle cell trait.3Patients with sickle
ization regimen.4 cell trait have about 40% hemoglobin S
—Intraoral hemorrhage is a constant and have no symptoms of the disease un­
threat to these patients. Any invasive pro­ less exposed to low oxygen pressure.
cedures included in orthodontic treat­ Routine orthodontic treatment can be
ment must be discussed with the attend­ provided w ith only a moderately in ­
ing physician and balanced against the creased complication risk compared with
risk of uncontrolled bleeding. If tooth ex­ normal patients.
traction or other surgery is required, these The situation is not so favorable for the
patients usually are hospitalized and giv­ 0.15% of black children in the United
en transfusions in advance of the proce­ States who have sickle cell anemia.3 Pa­
dure, with serum preparations that sup­ tients with sickle cell anemia have 75% to
ply the missing clotting factors. The indi­ 100% hemoglobin S and have such clini­
cations for invasive procedures must be cal manifestations of sickle cell anemia as
carefully evaluated, but such procedures jaundice, pallor, or painful infarctions (or
are not contraindicated if effective re­ all three). Chronic anemia, slow healing,
van Venrooy—Proffit: ORTHODONTIC CARE FOR MEDICALLY COMPROMISED PATIENTS ■ 263
ARTI CLES

and delayed dental development are currently classified into three categories
likely to be in evidence. Medical treat­ Type I, insulin-dependent diabetes mel
ment is limited to symptomatic care using litus (IDDM), formerly referred to a:
supportive care and blood transfusion juvenile diabetes, juvenile-onset diabe
during acute episodes. Transfusion poses tes, or brittle diabetes; type II, non-insulii
an increased risk of hepatitis, and appro­ dependent diabetes mellitus (NIDDM)
priate patient and office precautions are also termed adult-onset or stable diabetes
indicated. Transfusion also increases the and other types, previously known a;
chances that the sickle cell patient will secondary diabetes.12 A patient with anj
develop iron overload. A vaso-occlusive type of diabetes will have hyperglycemi;
or an aplastic crisis may be triggered by and may show the traditional symptom:
infection or trauma. During a vaso- of the disease (polyphagia, polydipsia
occlusive crisis, the patient is severely ill, polyuria, weakness, severe periodonta
as the result of peripheral sickling of red breakdown, and delayed wound healing)
blood cells under low oxygen tension and As approximately half of the patienti
consequent red blood cell lysis. Pain, es­ with diabetes are undiagnosed, a denta
pecially in bones of children, and tis­ examination may provide the first indica
sue ischemia are present. Severe anemia tion that the disease is present. Any pa
with a distinct reduction in hemoglobin tient with suspected diabetes should b(
content ensues. During an aplastic crisis, referred for medical evaluation. Regula
which may also be triggered by folic acid tion of diet and activity, insulin adminis
deficiency, the bone marrow temporarily tration, and oral hypoglycemic drugs an
Fig 2 ■ Twelve-year-old patient with insulin-
ceases red blood cell production, with re­ dependent diabetes mellitus (IDDM) at presentation current forms of appropriate medica
sultant severe anemia. In either type of for orthodontic evaluation. Generalized plaque and treatment.
crisis, there is significant morbidity and exaggerated tissue response (pyogenic granuloma) The key to any orthodontic treatmen
mortality. are notable. for a patient with diabetes is good medi
The major concern in providing ortho­ cal control. Orthodontic treatment shoulc
dontic care for these patients is that an not be done for a patient with uncon
Orthodontic treatment can be provided,
oral infection can trigger a life-threat­ trolled diabetes, but may be done fo
during long-term remission, for a child
ening crisis. For this reason, invasive those in whom therapy has establishec
who is no longer receiving chem o­
procedures require extreme caution and good control of blood glucose levels anc
therapy, within the context of the physi­
tissue irritation must be avoided. Ortho­ clinical symptoms. Periodontal break
cian’s recommendations. Reduced resis­
dontic therapy requires discrete goals and down may be one of the first signs of losi
tance to infection is a common problem in
should be of limited duration. General of control on the disease (Fig 2), so carefu
these children. Allowing dental caries to
anesthesia should be avoided for patients m onitoring, in c lu d in g intraoral ra
progress to the point of pulp exposure
with sickle cell trait and sickle cell diographs at frequent intervals, is re
and abscess form ation can be life-
anemia as it may reduce blood oxygen quired.
threatening in such a child, and any oral
saturation. Orthognathic surgery rarely, if Of patients with clinical diabetes, thos<
infection or irritation is a serious prob­
ever, can be considered because of the with IDDM differ from those with NIDDN
lem. A ntibiotic prophylaxis may be
anesthetic risks. in that the pancreatic islets usually an
needed for any invasive procedures. As in
destroyed, leaving the patient totally de
other children with blood dyscrasies,
pendent on exogenous insulin. This con
Treated leukem ia fixed appliances with bonded attach­
dition is seen most often in younger pa
ments are preferred, and chronic mucosal
Leukemia is a malignant disease of the irritation must be avoided. tients. A child with IDDM can be pre
blood marrow elements characterized by sumed to be “brittle” in the sense tha
Xerostomia (dry mouth), caused by a
altered forms and numbers of leukocytes decrease or absence of normal salivary strict compliance with the medical regi
and, rarely, erythrocytes. It is classified secretions, can also complicate orthodon­ men is required to maintain control o
by its course (acute or chronic), cell type tic therapy in these patients. Xerostomia blood glucose levels. Deviations from ap
(myeloid, lymphoid, monocytic, eryth­ may occur after radiation to the head and propriate diet and from the schedule o
rocytic) and number of abnormal leuko­ neck, but may also be a sequela of chemo­ in s u lin injections result in distinc
cytes (in c re a s e d — le u k e m ic , d e ­ therapy. When the lubricating and an- changes in the serum glucose level. /
creased— aleukemic). Until the 1960s, ticarious actions of saliva become lost, well-controlled juvenile diabetic patien
acute leukemia in children was uniformly both carious attack on the teeth and ul­ is a reasonable orthodontic risk (Fig 3)
and rapidly fatal. Progress in treating ceration of the mucosa are more frequent. but a diabetic child undergoing com
childhood leukemias with combined Daily topical fluoride application and prehensive orthodontic treatment mus
chemotherapy (m ultiple chemothera­ immaculate oral hygiene are essential. In be monitored especially carefully. If ai
peutic agents) has been steady. For acute most Western countries, but not in the adolescent rebellion involves rejection o
lymphocytic leukemia, the most preva­ United States, 0.2% chlorhexidine has the medical protocol, the results can b<
lent childhood leukemia, the 5-year cure been approved for use as a mouthrinse tragic.
rate reached 50% by the mid-1970s9 and and is a helpful adjunct to dental
continues to improve. These children, in hygiene.10 Severe xerostomia, however, Cystic fibrosis
some instances, are seeking orthodontic may contraindicate orthodontic therapy.
treatment. As there are many types of Cystic fibrosis is the most common letha
leukemia, the patient’s physician must be genetic disease in the white population
Other diseases
consulted to determine the individual’s Its incidence is estimated at 1 in 1,600 livf
prognosis and potential complications. Diabetes mellitus births in the United States.13 The condi
As a general rule, no dental procedure tion is characterized by unusually high
should be done during or immediately It is estimated that 2% of the US popula­ sodium levels in sweat, exocrine glanc
after chemotherapy or radiation therapy. tion has diabetes mellitus.11 Diabetes is dysfunction, difficulty in managing se-

264 ■ JA D A , Vol. I l l , A ugust 1985


prêtions (especially in the tracheo­
bronchial area), and eventual pulmonary
'ailure. When cystic fibrosis was iden-
:ified in the 1930s, the disease was gener-
illy fatal before school age. By 1975, the
nedian survival was 19.4 years.13Current
nedical therapy uses antibiotic treatment
or the frequent pulmonary infections and
i high salt diet to replace secreted
îlectrocytes, but the slow decline in pul-
nonary function remains relentless.
A major problem in evaluating the ben-
îfits of comprehensive orthodontic
reatment for a child with cystic fibrosis is
he variation in life expectancy, which
;an range from months in severe cases to
possible decades. Parents of these chil-
iren, like others who have children with
:hronic medical problems, often are
notivated to extensively use dental and
nedical facilities, and often seek ortho­
dontic consultation. A frank evaluation
3y the patient’s physician of the severity
)f the problem and the patient’s life ex-
nectancy is a necessary component in any
valuation of possible orthodontic treat-
nent.
The salivary glands, particularly the
submandibular gland, often are affected
n cystic fibrosis. Both salivary volume
md quality are reduced, resulting in a
:onsiderably increased risk of caries and
iecalcification around orthodontic ap-
üliances. For the majority of these chil­
dren, orthodontic therapy should be lim-
ted in scope if attempted.
\rthritis
\rthritic disorders are important consid-
srations in planning orthodontic treat­
Fig 3 ■ Adolescent patient with insulin-dependent diabetes mellitus (IDDM) with Class II, division 1 malocclusion complicated
by absence of maxillary left lateral incisor and peg-shaped right lateral incisor. Orthodontic correction entailed extraction of
maxillary right lateral incisor and 2 years of fixed appliance therapy. Maxillary canines were reshaped and substituted for lateral
incisors. Course of treatment was unremarkable with moderate gingival hyperplasia. Left, pretreatment, and right, day of
debanding.
ment for both children and adults because
they can involve the temporomandibular
joint (TMJ) and because the side effects of
drug treatment can be significant even if
the TM) is not involved directly.
Rheumatoid arthritis is the major arthritic
problem in children and young adults,
whereas osteoarthritis is relatively fre­
quent in older patients.
Rheumatoid arthritis is a chronic sys­
temic inflammatory disease of unknown
cause that manifests itself at any time be­
fore mid-life and can develop in children.
It usually affects multiple symmetrical
small joints of the body. The diagnosis of
rheumatoid arthritis of the TMJ, there­
fore, will be aided by a positive history of
rheumatoid arthritis involving other
joints. Rheumatoid arthritis in children
can be self-limiting but often is progres­
sive, with irreversible damage to the joint
spaces. Classic signs of rheumatoid de­
struction of the TMJ include condylar
flattening and a large joint space. An­
kylosis is less common than with osteo­
arthritis, but with early onset of the dis­
ease, overall growth of the mandible may
be limited, resulting in a severe Class II
jaw discrepancy. Destruction of the con­
dylar process may occur in severe cases.
Treatment procedures that stress the
TMJ should be avoided in patients with
rheumatoid involvement of that joint.
This includes functional appliances to
posture the mandible forward, heavy
Class II elastic bands, and surgical ad­
vancement of the mandible. Thus,
skeletal mandibular deficiency cannot be
treated directly in these patients without
potential exacerbation of the joint dis­
ease. For a child with rheumatoid ar­
van Venrooy-Proffit: ORTHODONTIC CARE FOR MEDICALLY COMPROMISED PATIENTS ■ 265
ARTI CLES
thritis and deficient mandibular growth,
headgear to the maxilla does not cause
complications. At a later stage, if orthog­
nathic surgery is needed, vertical maxil­
lary repositioning combined with genio-
plasty is the most conservative approach.
Mandibular surgery and surgical in­
volvement of the TMJ should be avoided
if at all possible. For a child with arthritis
and early TMJ ankylosis, condylectomy
and a costochondral rib graft may be nec­
essary,14 but the prognosis is guarded at
best.
Osteoarthritis is the most common form
of arthritis in the TMJ. Its incidence in­
creases with age, and it tends to occur in
multiple large joints of the body, particu­
larly the weight-bearing joints. Degenera­
tive joint disease is a more accurate term
for osteoarthritis, as the disease is
noninflammatory and is limited to the
joints. Degenerative changes in the TMJ
can lead to limitation of movement, pain,
decreased joint space, and bony an­
kylosis. This condition should be consid­
ered in the evaluation of older adult pa­
tients with a history of progressive, uni­
lateral TMJ dysfunction.15 Altering the
dental occlusion, whether orthodon-
tically or by other means, is not adequate
treatment by itself for arthritic degenera­
tion of the TMJ. However, alterations of
the dental occlusion may be an appropri­
ate part of a treatment plan for older pa­
tients who have degenerative joint dis­
ease, and adjunctive orthodontic treat­
ment can be included without undue
risks.
The adverse reactions associated with
anti-inflammatory drugs are a major con­
cern for both groups of arthritis patients.
ART I CLE S
Treatment procedures that stress the TMJ, including functional appliances
to posture the mandible forward, heavy Class II elastic bands, and surgical
advancement of the mandible, should be avoided in patients with
rheumatoid involvement of that joint.
Both osteoarthritis and rheumatoid ar­
thritis are treated symptomatically with
analge sics and w ith ste roid al and
nonsteroidal anti-inflammatory agents.
When arthritic patients are receiving
anti-inflammatory drugs the patient’s
physician should be asked to assess pos­
sible drug-related complications. With
long-term steroid therapy, resistance to
infection (and to stress in general) is de­
creased, so that periodontal disease may
develop and progress rapidly.
Cardiovascular disease
Cardiovascular diseases are prevalent in
the general population and are the lead­
ing cause of death in North America, mak­
ing the likelihood of encountering adult
or ch ild patients w ith some form of
cardiovascular disease quite high.11 Pa­
tients with congenital heart disease, car­
diac damage from rheumatic fever or
other causes, a prosthetic heart valve, or
recent cardiovascular surgery require an­
tibiotic prophylaxis to prevent bacterial
endocarditis whenever there is a chance
of bacteremia from dental treatment.
Death resulting from bacterial endocar­
ditis has been documented after routine
dental procedures.16There is no reason to
expect potentially invasive orthodontic
procedures such as band placement and
cementation to represent a lesser risk.
However, most routine orthodontic ap­
pliance adjustments are not invasive, and
antibiotic coverage is not needed for
every orthodontic appointment.
The prognosis for many children with
congenital heart defects is favorable, and
there is no reason to withhold orthodon­
tic therapy. Antibiotic coverage is needed
for the initial appointments at which ap­
pliances w ill be placed, for long or com­
plex appliance changes and adjustments,
and for appliance removal. Maintenance
of excellent oral hygiene to reduce the
tendency for gingival inflammation is
particularly important in these patients.
When it is required, antibiotic coverage
for orthodontic appointments is the same
as that for other dental treatment. For
adults, the American Heart Association
recommends potassium penicillin V, 2
gm orally 1 hour before a dental proce­
dure, followed by 1 gm 6 hours later.17
266 ■ JA D A , V ol. I l l , A ug ust 1985
Patients who are allergic to penicillin
should receive erythromycin, 1 gm orally
1 hour before, followed by 500 mgm 6
hours later. Somewhat smaller doses can
be used for children. These general rec­
ommendations should be adjusted in
consultation with the attending physi­
cian.
Anticoagulant, antihypertensive, and
diuretic agents are frequently used in the
treatment of cardiovascular disease in
adults. Excessive bleeding, xerostomia,
and hypotension can all be significant
side effects of these drugs. The same pre­
cautions necessary for routine dental
treatment, however, are adequate for ad­
junctive orthodontic treatment that is
limited in scope and duration.
Summary
Medically compromised children and
adults are increasingly likely to seek or­
thodontic care as improved medical man­
agement creates more long-term sur­
vivors. For the majority, treatment of or­
thodontic problems is feasible, but spe­
cial precautions usually are required.
These include medical consultation to es­
tablish the patient’s prognosis, maintain­
ing a current knowledge of drug therapy,
and modifications in office procedures.
Patients with a history of multiple trans­
fusions should be presumed to be hepati­
tis carriers until proved not to be, and
special precautions to protect office staff
members and other patients should be
taken. Decreased resistance to infection is
a common complicating factor in medi­
cally compromised patients. Dentists
must therefore avoid mucosal irritation
and carefully monitor periodontal health.
The practitioner should be alert to side
effects of drug treatment such as xerosto­
mia and depressed immune response,
and be aware of the particular features of
the underlying disease. Bleeding disor­
ders, which can be managed by replace­
ment of missing clotting factors, do not
contraindicate orthognathic surgery. The
major contraindication is poor anesthetic
risk, which almost always is true for pa­
tients having sickle cell anemia because
of poor blood oxygen saturation. Because
orthodontic treatment can provide posi­
tive benefits, it should not be withheld
solely because of the presence of a serious
medical problem. With appropriate man­
agement, successful orthodontic treat­
ment can be done for most patients.
_________________________________ J W O A
Dr. van Venrooy is assistant professor, and Dr. Prof-
fit is professor and chairm an, departm ent of ortho­
dontics, School of Dentistry, University of N orth
Carolina, Chapel Hill, NC 27514. Address requests for
reprints to Dr. van Venrooy.
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