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Orthodontic care of medically compromised patients

Article in Indian Journal of Oral Sciences · January 2012

DOI: 10.4103/0976-6944.111174

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Juhi Ansar Sandhya Maheshwari

Rohilkhand Medical College and Hospital Dr. Z. A. Dental College
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Review Article
Orthodontic care of medically
compromised patients
Sandhya Maheshwari, Sanjeev Kumar Verma, Juhi Ansar, KC Prabhat
Department of Orthodontics and Dental Anatomy, Aligarh Muslim University, Aligarh, India

ABSTRACT

Advances in the treatment of medical conditions have resulted in long-term disease-free

survival. Consequently, many of these patients are now seeking orthodontic therapy. This
article will discuss various systemic diseases, their effect on orthodontic treatment and the
recommended methods to avoid the potential problems that may arise.

Key words: Guidelines, interdisciplinary management, life expectancy, medically compromised patient,
orthodontic considerations, orthodontic treatment

Introduction Orthodontic considerations

Address for Correspondence:
Dr. Juhi Ansar,
Department of Orthodontics and
Dental Anatomy,
Dr. Z. A. Dental College,
Aligarh Muslim University,
Aligarh ‑ 212 001, India.
E‑mail: Juhiortho10@gmail.com
Date of Submission: 13‑07‑2012
Date of Acceptance: 14‑01‑2013
Access this article online
Website:
www.indjos.com
DOI:
10.4103/0976-6944.111174
Quick Response Code:
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.[1] 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.[2] 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;
Infective Endocarditis
Bacterial endocarditis is a relatively
uncommon, life‑threatening infection
of the endothelial surface of the heart,
including the heart valves.[3] 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 bacteremias of oral
origin are proportional to the degree of oral
inflammation and infection.[4]
• O
 rthodontist 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.[5]
• T
 he importance of maintaining an
exemplary standard of oral hygiene and
that it is their responsibility to protect
themselves.
• T
 he main orthodontic procedure that has
been postulated to cause a bacteraemia
has been placement of a separator.[6]
• O
 rthodontics should avoid using
orthodontics bands instead use, bonded
attachments. If banding is required use
of antibiotic prophylaxis is must.[7]
• A
 ntibiotic prophylaxis is only required
in high-risk patients and the drug of
choice is penicillin.[4]
Hemophilia
Hemophilia is the most common congenital
bleeding disorder.[8] 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 Willebrand’s disease (defects of
von Willebrand’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%.[9]

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Maheshwari, et al.: Orthodontic care of medically compromised patients
Orthodontic considerations
• O rthodontic treatment is not contraindicated in patients
with bleeding disorders.[10]
• D uration of treatment should be given careful
consideration. Lengthier the treatment duration may
increase potential complications.[11]
• C hronic irritation from orthodontic appliances
should be avoided. Fixed appliances are preferable to
removable appliances as the latter can cause gingival
irritation.[7]
• S elf‑ligating brackets are preferable to conventional
brackets. If conventional brackets are used, archwires
should be secured with elastomeric modules instead of
wire ligatures.
• I f extractions or surgery is to be performed increase
factor VIII production with 1-desamino-8-darginine
vasopressin (DDAVP). Parentaral DDAVP can be used
to raise factor VIII levels 2‑3‑fold to prevent surgical
hemorrhage.[12]
Hematological Malignancies
More than 40% pediatric malignancies are hematological
either leukemia or 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.[13] 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.[14]
Orthodontic considerations
• I n these patients intense chemotherapy weakens
regenerative capacity of mucosa. Minor irritation can
lead to opportunistic infection and subsequent severe
complications.
• U se 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.[15] The lower jaw
is at risk of osteoradionecrosis (ORN) because of its
limited blood supply. A group of 104 patients who
developed ORN of the jaws were reviewed and treated
between 1972 and 1992. The most common affected
site was the mandible (99 cases, 95.2%), followed by
the maxilla (5 cases, 4.8%). Among all cases, 93 (89.4%)
were trauma induced‑ORN.[16]
• O rthodontic 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%.[17]
130
• A
 traumatic extraction procedures are reported to
reduce the risk for ORN.
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.[18] Based on
their clinical and genetic orders they are classified into
major (homozygous) and minor (heterozygous) types.[19]
β‑Thalassemia major (Cooleys 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.[20,21] the
overdevelopment of the maxilla frequently result in an
increased overjet and spacing of maxilla teeth and other
degree of malocclusion.[22]
Orthodontic consideration
• Patient who have undergo splenectomy are at
massive risk of infection followed by bacterimia.[23]
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.[23]
• 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 thalassemic
patients.[24]
• 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.[23]
• Thalassemic 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.
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.[25] Signs
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Maheshwari, et al.: Orthodontic care of medically compromised patients
and symptoms of asthma, include intermittent wheezing,
coughing, dyspnea, and chest tightness.
Orthodontics considerations
• I nhaled corticosteroids are the most widely used and
most effective asthma anti‑inflammatory agents.[26]
• O ral manifestations include candidiasis, decreased
salivary flow, increased calculus, increased gingivitis,
and increased periodontal disease.[27]
• S chedule these patients’ appointments for late morning
or later in the day, to minimize the risk of an asthmatic
attack.
• J udicious use of rubber dams should be avoided as they
reduced breathing capability.
• C are should be used in the positioning of suction tips
as they may elicit a cough reflex.
• U p to 10% of adult asthmatic patients have an allergy
to aspirin and other nonsteroidal anti‑inflammatory
agents.[28] 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.
Epilepsy
Epilepsy is the most common serious chronic neurological
condition. It is as a chronic neurological disorder
characterized by frequently recurrent seizures. [29] The
risk of developing epilepsy is 2‑5% over a lifetime.
It affects about 0.5-2% of the population.[30] Injuries
to the tongue, buccal mucosa, facial fractures, avulsion,
luxation or fractures of teeth and subluxation of the
temporomandibular joint can occur during seizures.[31]
Both the condition and the medical management of
condition can affect oral health.
Orthodontic considerations
• T
 he orthodontist should ensure the patient is receiving
regular and rigorous preventative dental care to
avoid/minimize dental disease.
• G
 ingival 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.
• R
 emovable appliances should be used with caution as
they can be dislodged during a seizure.[32]
• W
 herever possible removable appliances should be
designed for maximum retention and made of high
impact acrylic.
• T
 he metal in a fixed orthodontic appliance may
distort images obtained by magnetic resonance
imaging (MRI).[33] An acceptable MRI may be obtained
if arch wires and other removable components are
removed before the scan.
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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.[34] 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
• T he 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.[35]
• I mportance 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.
• A pply 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.
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.[36,37] 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 disease progresses
dialysis or transplantation are required. Many patients are
prescribed steroids to either combat renal disease or to
avoid transplant rejection
Orthodontic considerations
• E
 xtraction 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.[36]
• D
 ue to the increase in circulating parathyroid hormone.
It has been suggested that orthodontic treatment forces
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Maheshwari, et al.: Orthodontic care of medically compromised patients
should be reduced and the forces re‑adjusted at shorter
intervals.
• R enal insufficiency is considered a risk condition for
IE if the patient does not have a good control of the
disease.[38] Antibiotic prophylaxis should be consider in
hemodialyzed patients who were undergoing an invasive
dental procedure.[36]
• D uring 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.
• M any antibiotics are actively removed by the kidney, so
adjustment of the dosage by amount or by frequency
is required. [39] Penicillin and its derivates are the
preferred antibiotics for these patients. In the case of
non‑narcotic analgesics, paracetamol is the best choice.
• I n 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.[40]
•  ingival overgrowth secondary to the immunosuppressive
G more root resorption, suggesting that in subjects where
therapy is the most studied oral manifestation. Nifedipine
increases the prevalence of gingival overgrowth.[41]
Gingival overgrowth can impede tooth movement
during orthodontic treatment. Gingivectomy should be
considered in such patients.
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. [42] Risk factors that cannot be altered
include advanced age, being female, estrogen deficiency
after menopause.[43] Potentially modifiable risk factors
include excessive alcohol intake, vitamin D deficiency, and
smoking.[44] Drugs most commonly used in treatment of
osteoporosis are bisphoshonate (BP), estrogen, and calcitonins.
Orthodontic considerations
• O
 rthodontic treatment therefore, must include the
consideration of problems such as bone loss, retention
instability, and temporomandibular dysfunction.[45]
• P
 roblem associated with medication must also be
given consideration. Estrogen decreases the rate of
tooth movement.[46] However, if these drugs are not
used during orthodontic treatment in patients with
osteoporosis, resorption of alveolar bone and possibly
tooth roots could occur.
132
• U
 se of BP can affect orthodontic treatment by delaying
tooth eruption, inhibited tooth movement,[47] impaired
bone healing, and by causing BP‑induced (ORN) of the
jaws.
• E
 xtraction protocol and use of temporary anchorage
devices should be avoided.[48]
• B
 P inhibits osteoclasts, decreases microcirculation and
thus impedes tooth movement.
Thyroid and Parathyroid Disorders
After DM, thyroid disease is the most common endocrine
problem.[49] Thyroid diseases occur more often in women
and most often in women older than 50 years of age.
Orthodontic considerations
• O rthodontic therapy requires minimal alterations in the
patient with adequately managed thyroid disease.
• I n hyperthyroidism enlarged tongue may pose problem
during treatment.
• T he 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.
• L ow bone turnover (i.e., hypothyroidism) can result
a decreased bone turnover rate is expected, the risk of
root resorption could be increased.[50]
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).[51]
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.[52] Liver dysfunction alters the metabolism
of carbohydrates, lipids, proteins, drugs, bilirubin, and
hormones.[53]
Orthodontic considerations
• H
 epatitis B is a worldwide health problem, with an
estimated 400 million carriers of the virus.[54] It has been
calculated that 1.53% of all patients reporting to the
dental clinic are hepatitis B virus (HBV) carriers.[55] Viral
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Maheshwari, et al.: Orthodontic care of medically compromised patients
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.
• A erosols 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.[56]
• I nfection control protocol should be followed
according to the guideline laid down by occupational
safety and health administration.[57] All members of
the team should be immunized against HBV. Barrier
technique such as gloves, eye glasses, and mouth mask
should be used.
• H BV 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 glutaldehyde or
by spraying sodium hypochlorite and leaving it for
10 min.[58]
• P ost-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. If the source individual is Hepatitis
B surface antigen (HBsAg) positive and the exposed
person is unvaccinated or antibody level is less than
10 mIU/ml, hepatitis B immunoglobulin (0.6 ml/kg) should
be administered (preferably within 24 h) along with the
vaccine series given at a different site.[59]
• L iver 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.[60,61]
• C are 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.[62] Caution should be used in
prescribing medications metabolized in the liver, such
as acetaminophen, nonsteroidal anti‑inflammatory
agents.[63]
Down Syndrome
Down syndrome is one of the most common genetic
syndromes, occurring in one of 800‑1000 live births.[64] John
Langdon Down who published an accurate description
of a person with Down syndrome discovered Down
Indian Journal of Oral Sciences  Vol. 3  Issue 3  Sep-Dec 2012
syndrome in 1866, although he did not know the cause
of the syndrome. He was then termed the “father” of the
syndrome.[65]
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.[66] In many instances this causes a prognathic class III
occlusal relationship, which contributes to an open bite.[66]
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
• C ongenital 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.[67]
• R educed 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.[66] hence oral hygiene instruction should be
given in every visit.
• I t 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.[68]
• S eizures occur in 5‑10% of children with Down
syndrome.[69] 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.
• H igh‑memory wires allow a longer activation interval
between appointments.
• S elf‑ligating brackets allow a more patient‑friendly
activation appointment.
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.[70] The typical presenting symptoms
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Maheshwari, et al.: Orthodontic care of medically compromised patients
of autistic disorder are delayed speech or challenging
behavior before 3 years of age.[71] 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.[72] The reported incidence of
autistic disorder ranges from about 5 per 10,000 to 20 per
10,000 persons.[73] 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.[74] Some reports have suggested a possible
association with Down syndrome.[75] In addition to the
implication of neuro‑transmitters, such as serotonin, in
the development and expression of autism.[76] 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
• T he main challenge to the orthodontic team may be
the reduced ability of autistic patients to communicate
and relate to others.
• T he first several visits are directed towards raising the
patient’s confidence and determining the maximum
level of compliance that is achievable.
• A t 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.[77]
• T he 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.[78]
• J ackson was the first to suggest using GA for the
placement of orthodontic bands.[79]
• P atient should be treated in a quiet, shielded single
operatory versus an open‑bay arrangement, with
reduced decoration and dimmed lights.[80]
• Procedures such as tell‑show‑do, voice control, and

positive reinforcement are effective with children.[81]
• T he effectiveness of reinforcers can vary among
children with autism spectrum disorder (ASD).[82]
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.[83]
134
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.[84] TB 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.[85]
Orthodontic considerations
• P
 atients with a medical history or symptoms indicative of
undiagnosed active TB should be referred promptly for
medical evaluation to determine possible infectiousness.
• E
 lective dental treatment including orthodontics
treatment should be deferred until a physician confirms
that a patient does not have infectious TB.
• T
 B 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).
• T
 he challenge to orthodontics is to be prepared for all
infectious diseases that may affect the practice.
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.[86] 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.[87]
Orthodontic considerations
• H
 IV infection does not necessitate changes in the
orthodontic treatment plan for a child or adolescent.
However, effects of HIV infection on the pediatric
patient and the patient’s family may alter the clinician’s
approach to treatment.
• M
 any 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.
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Maheshwari, et al.: Orthodontic care of medically compromised patients
Therefore, it is critical that the oral hygiene and health References
of children and adolescents receiving ARV medications
be attended to daily. 1.
•  ccording to the Public Health Laboratory Service,[88] as
A patients: Cardiac disease, bleeding disorders and asthma. Semin Orthod
of June 1999, there were 319 reports of occupationally 2.
acquired HIV among health care workers worldwide.
Of these, 102 cases were confirmed. Of the 217 3.
possible or probable cases, 9 were dental workers.
•  ercutaneous injuries and blood splashes to the
P 4.
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. [89] The highest
frequencies of percutaneous injuries were reported by
orthodontists (4.9 per year) and the highest frequencies
5.
of blood splashes to the eyes, nose or mouth were
reported by oral surgeons (1.8 per year). 6.
•  niversal infection control procedures should be
U odontogenic bacteraemia and orthodontic treatment procedures.
employed for all patients irrespective of their health status.
7.
•  he potential for allergic reactions and drug resistance
T
increases over time with increased usage and may 8.
increase with decreased immune function; therefore,
the judicious use of antibiotics is warranted.
•  uring the visits the patient must be stimulated to recognize
D 9.
their fundamental importance in maintaining oral health.
Patients must also be stimulated to use additional auxiliary 10.
procedures such as antiseptic mouthwashes.[90]
•  erostomia has been observed in pediatric patients.
X 11.
Clinicians should recommend sugarless gum and
frequent consumption of water or highly diluted fruit 12.
juices to alleviate xerostomia.
•  ost‑exposure prophylaxis (PEP) should be given
P 13.
immediately after the accidental occurrence. PEP for
HIV exposure is best when started within golden period 14.
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 15.
inhibitor (NRTI)) or expanded regimen (2 NRTI and
1 Protease inhibitors (PI) drugs). NACO recommend 16.
zidovudine/stavudine + lamivudine (basic regimen) and
zidovudine + lamivudine + lopinavir/ritonavir.[91‑93] 17.
Summary
An orthodontist needs to recognize various medical 18.
conditions and their impact on treatment procedures.
19.
Treatment should where appropriate be postponed until the
medical problem is in remission or the side effects of the 20.
drug therapy are minimized. Comprehensive treatment may
not always benefit the patient. Treatment procedure should 21.
be modified according to need. Consent before treatment,
22.
Good patient cooperation and constant monitoring of
the progress of the treatment are necessary to minimize 23.
physical damage and to maximize treatment outcome.
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How to cite this article: Maheshwari S, Verma SK, Ansar J, Prabhat
KC. Orthodontic care of medically compromised patients. Indian J Oral
Sci 2012;3:129-37.
Source of Support: Nil, Conflict of Interest: None declared

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