Medical disorder considerations in

orthodontic patients

PRESENTED BY:-
SHUBHANJALI SHARMA
PRECEPTOR:
DR.PIUSH KUMAR

1
 Contents
• Who is a medically compromised patient?

• Bacterial infections:
Sub-acute bacterial endocarditis

• Blood dyscariasis:
 Haemophilia
 Anaemia
 Leukemia

• Hypertension
• Liver diseases
• AIDS

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• Respiratory disorders:
Asthma
Management of upper airway obstruction- adenotonsillar hypertrophy

• Adverse hypersensitivity reactions

• Neural disorders:
• Seizure disorders-epilepsy

• Metabolic disorders:
Diabetes
Osteoporosis

• Kidney disorders
• Psychiatric issues:
Children with “special needs”
Conclusion & references
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• A medically compromised dental patient in general is -

“A dental patient who has a general health

condition (physical, mental, emotional, medical)
& who must modify their activities from “normal” and
require some kind of modification in the usual pattern of
receiving oral health care”.
INFECTIVE ENDOCARDITIS
• microbial infection of a heart valve(native/prosthetic) or the
lining of a cardiac chamber or blood vessel.

• Caused by: Staphylococcus aureus, Viridans group,

enterococci

• Infection tends to occur at sites of endothelial damage.

• When the infection is established, vegetations, composed of

organisms, fibrin & platelets grow & may become large
enough to cause obstruction; they may also break away as an
emboli which could be fatal.

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HIGH RISK-ENDOCARDITIS prior history of endocarditis, those who
have prosthetic valves or surgically
corrected systemic pulmonary shunts or
conduits,or those with congenital heart
disease.

MODERATE RISK-ENDOCARDITIS congenital cardiac malformations,

acquired valvular dysfunction(rheumatic
heart disease) hypertrophic
cardiomyopathy & mitral valve prolapse
with regurgitation.

NEGLIGIBLE RISK-ENDOCARDITIS Isolated atrial or ventricular septal

defects
Patent ductus arterious
Previous coronary artery bypass graft
Mitral valve prolapse without valvular
regurgitation

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 ANTIBIOTIC PROPHYLAXIS

• It is recommended to use of antibiotic prophylaxis before the

following dental procedures:
• Extractions
• Scaling
• Surgery involving the gingival tissues
• NO specific recommendations about the use of antibiotic
prophylaxis prior to orthodontic banding or removal.
• The AMERICAN HEART ASSOCIATION recommendations state
that antibiotic prophylaxis should be given at the initial
placement of orthodontic bands BUT NOT orthodontic
brackets.
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• The current recommendations for endocarditis prophylaxis by
the American Heart Association are:

ADULTS 2g of penicillin
CHILDREN 50mg/kg of penicillin

Administered 1 hour before the procedure

• For penicillin-allergic patients, clindamycin
600mg for adults & 20mg/kg body weight for children is
recommended.

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• If a patient forgets to take his/her premedication, or if
unanticipated bleeding occurs, the American Heart Association
guidelines suggest that antibiotic given at the time of
treatment or up to 2 hours from the time of insult is effective.

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WHAT SHOULD THE ORTHODONTIST DO ?

• a case by case approach in agreement with the patient’s

cardiologist.

• Orthodontic treatment should never be commenced until the

patient has exemplary oral hygiene and excellent dental health.

• As the prevalence and magnitude of bacteraemias of oral

origin are directly proportional to the degree of oral
inflammation and infection.
1. Hence, it is advisable to use 0.2% chlorhexidine mouthwash.
2. use bonded attachments.

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• Ask for penicillin allergy.

• The latest American guidelines recommend the use of

antibiotic prophylaxis for initial banding, but not when
removing bands.

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 PATIENT WITH BLEEDING PROBLEMS

• The detection of bleeding problem in the dental patient is

precipitated far too often by the removal of a tooth or by some
other form of oral surgical procedures.

• Thus, the proper approach to the management of the patient

with bleeding problems begins with a thorough ,accurate
examination & diagnosis.

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DISEASES THAT LEAD TO BLEEDING
•PLATELETS
THROMBOCYTOPENIA
- NON IMMUNE
- IMMUNE
POORLY FUNCTIONING PLATELETS WITHOUT
THROMBOCYTOPENIA
•COAGULATION
CONGENITAL
- HEMOPHILIA A
- HEMOPHILIA B
- VON WILLEBRAND’S DISEASE

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• HEMATOLOGIC MALIGNANCIES
- LEUKEMIA
- POLYCYTHEMIA
- THROMBOCYTHEMIA

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• Bleeding disorders therefore result from qualitative or
quantitative deficiencies, or inadequate or insufficient levels of
plasma-clotting factors.

• Platelet deficiencies of interest to the orthodontist are

associated with conditions that result in a reduction of platelets
or THROMBOCYTOPENIA

• Thrombocytopenia may result from a reduction in the

production of platelets caused by disruption of the bone
marrow.

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leukemia malignancies thrombocytopenia diagnosis of leukemia
involving the bone associated with or aplastic anemia is
marrow leukemia is the result made, removal of
of malignant cells existing orthodontic
crowding normal appliance is
marrow stem cells mandatory to
minimize the risk of
gingival or mucosal
aplastic anemia autoimmune same result as a irritation, bleeding or
conditions in which consequence of auto infection.
the platelet- antibodies that
producing cells in the destroy normal cells.
marrow are
destroyed

• Both leukemia & aplastic anemia not only affect stem cells that
produce platelets but also eliminate the production of
infection-fighting neutrophils, resulting in NEUTROPENIA
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• In either case, patients presenting with spontaneous gingival
bleeding warrant an immediate referral for further
investigations.

• if an orthodontic patient is diagnosed with a malignancy &

requires chemotherapy, orthodontic treatment should be
postponed or interrupted and all orthodontic appliances should
be removed until anti-neoplastic therapy is completed.

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• factor-related diseases are most often congenital, as a result
the orthodontist should be able to determine the presence of
these conditions before the initiation of treatment.

• 3 congenital clotting factor deficiencies account for more than

90% on inherited disorders –

Hemophilia A

Hemophilia B

Von Willebrand’s disease

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• WHAT IS HEMOPHILIA?

• Hemophilia is a hereditary (X-linked, recessive) blood disorder

that affects the proper clotting of blood. It is a disease that
affects males much more frequently than females .This occurs
because a critical blood-clotting gene is carried on the X
chromosome.

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HEMOPHILIA-THE ROYAL DISEASE

• Hemophilia has often been referred to as The Royal Disease.

• The marriage of England's Queen Victoria and Prince Albert marked the
beginning of hemophilia in the British royal line.

• Queen Victoria, Queen of England from 1837 to 1901, was a carrier of

the hemophilia gene.

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21
 HEMOPHILIA B
(Christmas disease)

• Hemophilia B is a bleeding disorder caused by a mutation of

the Factor IX gene, leading to a deficiency of Factor IX. It is the
least common form of hemophilia, rarer than hemophilia A.
• It is sometimes called Christmas disease after Stephen
Christmas, the first patient described with this disease.
• In addition, the first report of its identification was published in
the Christmas edition of the British medical journal.

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MANAGEMENT OF HEMOPHILIA

• The hemophiliac who does not have circulating anticoagulant

can safely undergo dental treatment & oral surgery on an out
patient basis if correct medical treatment is used.

• Normal hemostasis & uneventful healing can be expected.

• Plan of treatment is the same for hemophilia A & B

patients who have clinically mild disease & require
preoperative treatment as much as those with
severe disease.

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 • It is essential that medical & dental treatment be synchronized.
Patient with no circulating
anticoagulant or mild
disease
hemophiliac with a
circulating
anticoagulant
Surgery early in day
EACA started 12 hour before surgery
Replacement factor conc 1 hr before
surgery. (25 units of factor VIII or 33
units of factor
IX /kg body Wt. iV if eaca used
EACA doses every 6 hours for 3-4
days if tissue trauma was minimal.
14-18 days if extensive dmage
preventive dentistry must be the
main objective.
These patients do not respond to
infusions of factor with the
expected rise in blood level;
Injections into the soft tissue &
injury to the other tissues must be
avoided.
dental procedures are carried out
exactly as in a non-hemophiliac patient
& no unusual post-operative steps are
taken other than continuation of EACA
& avoidance of hard foods for a little
longer.
The patient should be told to report
any unusual bleeding or swelling to
both the physician & dentist.
Should either bleeding or swelling
occur additional factor replacement is
necessary.
Extractions may be carried out in these
patients using pericemental &
peridental infiltration anesthesia &
higher than usual doses of EACA
intravenously
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 VON WILLEBRAND’S DISEASE
familial disorder of excessive post-traumatic When transfused with
coagulation bleeding & mucosal blood plasma or
an autosomal dominant bleeding because of lack cryoprecipitate, these
fashion. of factor V!! patients synthesize factor
VIII for several days.
Mild bleeding tendency is most common Therefore, surgery is
quite mild & may not be variantthere is an much easier than in
recognized until absolute deficiency of the hemophilia A patients,
adulthood entire factor VIII molecule since 2 or 3 units of
plasma given the day
before surgery will be all
that is needed.

If do not respond to plasma

transfusions in this manner.

treated by replacement with

factor VIII on the day of
surgery plus EACA as for the
patient with hemophilia A
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ORTHODONTIC CONSIDERATIONS

• biggest orthodontic-associated risk is the extractions associated

with the treatment.
• Mucosal damage by wires and appliance
• Care should be taken in the placement & removal of orthodontic
hardware to minimize the risk of mucosal injury.
• elastomeric modules are preferred to wire ligatures.
• overall treatment should be performed as expeditiously as
possible.
• To minimize the risk & cost to the patient, perform all planned
extractions at a single visit.
• The longer the duration of treatment, the greater the potential
for complications.
• orthognathic surgery to correct a severe jaw discrepancy may be
a better choice than prolonged ortho treatment
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• As with any invasive procedure, orthognathic surgery requires
preparation of the patient with transfusion to replace the
missing clotting factors.

• But with proper precautions surgery is entirely feasible.

PRECAUTIONS FOR MEDICAL PERSONNEL

Increased incidence of hepatitis in such patients because of
repeated transfusions. (considered carriers till proven otherwise)

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• These precautions include measures that prevent exposure to
serum or saliva such as the use of:

 Protective eyewear
 Gloves
 Facemasks

• Autoclaving or formaldehyde vapour pressure sterilization of all

instruments, including orthodontic pliers that may NOT be
routinely subjected to this sort of sterilization regimen.

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• Anemia, is defined as a reduction in the oxygen carrying
capacity of the RBCs, it is usually associated with decreased
RBCs or an abnormality in the Hemoglobin contained in the
RBCs.

• The clinical features of anaemia reflect diminished oxygen

supply to the tissue & depend upon the degree of anaemia, the
rapidity of onset & the presence of disease.

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 IMPORTANCE OF PATIENT HISTORY IN ANEMIA:

FAMILY HISTORY & ETHNIC hemolytic anaemias & pernicious anaemia may be
BACKGROUND suspected from family history

DRUG HISTORY: ingestion of drugs which can be associated with

blood loss.
e.g Aspirin

A DIETARY HISTORY assess the intake of iron & folate which may become
deficient in comparison to needs.e.g pregnancy &
lactation, during periods of rapid growth
PAST MEDICAL HISTORY May reveal a disease which is known to be associated
with anaemia, such as rheumatoid arthritis (anaemia
of chronic disease) or previous surgery (resection of
the stomach/small bowel which may lead to
malabsortion of iron&/vitamin B12)
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• DENTAL MANAGEMENT :
• the dentist should ensure that the patient’s underlying
condition is under therapeutic control before proceeding with
the dental treatment.

• In many cases, anemia is associated with chronic illness;thus,

treatment may be provided in the presence of anemia.

• patient’s Hb should be above 11g</dL and the patient should

be free from symptoms.

• In Patients who are short of breath & have Hb <11g/dL ,dental

treatment should be post-poned till the Hb levels increase.

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• Arrange short appointments.

• Avoid long & complicated procedures.

• Institute aggressive preventive dental care via -

• Oral hygiene instruction
• Diet control
• Tooth brushing & flossing
• Fluoride gel application

• Avoid oral infection; if present treat aggressively.

• Avoid liberal use of salicylates; control pain with

acetaminophen & codeine.

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• Effect on the orthodontic treatment :

• As anemia brings about decreased oxygen carrying capacity in

the RBCs.It may impair the cell turnover rate in the alveolar
bone thereby bringing about a delay in tooth movement.

• Care should be to apply optimum forces.

• Avoid therapeutic extractions whenever possible.

• On an average, the duration of orthodontic treatment is

extended.

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 LEUKAEMIA :

• Leukaemias are a group of malignant disorders of the

hemopoietic tissues characteristically associated with the
increased number of WBCs in the bone marrow and/or
peripheral blood.
• ORAL MANIFESTATION
sudden gingival bleeding
or gingival hyperplasia

gingival swelling leukemic infiltration in the areas of mild chronic irritation

ulceration of the sulcus epithelium & necrosis of the

gingival hemorrahage underlying tissue.

normal WBCs distribution is greatly disturbed, a normal

Ullceration inflammatory response to even a mild inflammation is
not possible.
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 ORTHODONTIC MANAGEMENT:

• Orthodontic treatment is an elective procedure for essentially

all patients & certainly for children & adolescents with cancer.

• It is most likely that the orthodontist will encounter children &

adolescents who are long term survivors of cancer or that
cancer is diagnosed during active orthodontic treatment.

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• Hence the orthodontist should make special considerations in
the treatment due to the health status of the child.

• The strategies to cope are :

1> Using appliances that minimize the risk of root resorption.
2> Using lighter forces.
3>Terminating the treatment earlier than normal.
4>Choosing simplest of the treatment methods based on the
patient’s need.

• Sheller & William, advised that after a patient has completed

the cancer therapy & has atleast 2 year event free survival,
orthodontic treatment should be initiated or restarted.

• This is based on the concern that young children are particularly

vulnerable to SECONDARY MALIGNANT NEOPLASMS.

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 HYPERTENSION
• Hypertension has been defined as sustained elevation in
arterial blood pressure resulting from increased peripheral
vascular resistance.

• The currently accepted normal value is 120/80mm of Hg ,upper

limit of “normal” blood pressure is 150/90mm of Hg for adults
over 18 yrs of age.

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 DENTAL MANAGEMENT:

The scope of dental management relative to the hypertensive

patient encompasses 3 basic activities:

1. SCREENING
2. REFERRAL
3. DENTAL TREATMENT MODIFICATIONS &
FOLLOW UP OF PATIENTS

• Referral & or consultation is one of the most important

functions of the dentist in providing comprehensive care .

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• Consultation with a physician regarding a patient with severe
hypertension or who appears to be non-compliant or refractory
to medical care is mandatory.

• Factors relating to the level of drug compliance, drug

interactions & the presence of other developing risk factors
may be discovered through this consultation.

• These complicated aspects of management may lead to the

modification of the treatment plan.

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The placement of a patient into one of the groups mentioned in
the following table allows for the more orderly progression of
dental management.
diastolic Emergency treatment Elective treatment

Stratum III (severe) ≥115mm of Hg consult consult

Stratum II (moderate) 105-114mm Either consider consultation or Refer & consult

of Hg provide treatment
Stratum I (mild) Provide treatment & refer Either consider consultation or
95-104mm Hg provide treatment & refer

Provide treatment & refer after

Provide treatment & refer after verification
90-94mm Hg verification

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 ASTHMA

• Episodic narrowing of the airways that results in breathing

difficulty characterizes asthma. It is most often the result of an
inherited immunologic hypersensitivity
reaction(allergic)disorder.

• Although the symptoms are reversible, the pulmonary distress

generated by asthma can be debilitating and, without doubt
adversely affects patient’s quality of life.
• pediatric asthma is common & almost half the cases of asthma
occurs before the age of 10yrs.
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 ORTHODONTIC MANAGEMENT OF ASTHMATICS :

• The first objective of the orthodontist should be to prevent

acute asthmatic attack.

• The medical history should specifically query for the condition,

regarding the severity of the disease (limitations in activities,
emergency room visits etc)

• Medications ,and factors that precipitate the attack should be

evaluated.

• If appropriate, has his/her inhaler present if needed during the

appointment.

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• Orthodontic treatment should be deferred in patients who
report symptomatic disease or have frequent flares despite
being adequately medicated.

• For patients with moderate or low risk, since anxiety & stress
are often associated with acute attacks – morning
appointments, when the patient is rested, short waiting times
& appointments of short duration are desirable.

• The orthodontist should ensure that the patient has taken

his/her medication before the procedure.

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 • Patients with asthma may be sensitive to several specific
medications including:
Erythromycins & azithromycin Patients who are taking theophylline preparations
should not be given erythromycin/azithromycin .
> >>
As the ingestion of these antibiotics may result in
toxic bloods level of theophylline.

Aspirin Can cause bronchial constriction

Barbituarates & narcotics > (e.g meperidine – histamine releasing )

L.A containing epinephrine Sulfite preservatives are found in local anesthetics

solutions that contain epinephrine.
“sulfites” are a cause of allergic-type of reaction in
susceptible individuals.

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• Chronic users of inhalers, especially those containing steroids,
may result in a predilection for the development of oral
candidiasis & xerostomia.

• If noted candidiasis should be treated with topical antifungal

agents.e.g NYSTATIN

• Xerostomia enhances the risk of dental caries.

• Consequently, aggressive oral hygiene , supplemental topical

fluorides & vigilance for any other dental disease is appropriate

45
• Orthodontic-induced external root resorption occurs with
greater frequency in patients with asthma than in the non-
asthmatic population.

• Further more in asthmatics who are on chronic steriod therapy,

increased difficulty in tooth movement may be encountered.

• It would therefore seem prudent, for the orthodontist to

disclose the risks & delays to patients before initiating
treatment.

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HYPERSENSITIVITY
REACTIONS

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• In modern orthodontic practice adverse patient reactions to
orthodontic materials are of both an IRRITANT &
HYPERSENSITIVITY.

• Hypersensitivity reactions are related to the antigenicity of some

materials that result in adverse patient response.

• The most common & problematic hypersensitivity reactions

• latex-based products
• alloy components of metal-based orthodontic appliances.
• Glove powder carrier of latex proteins

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• 2 distinct types of allergic reactions to natural rubber are
described in literature:

• TYPE I HYPERSENSITIVITY: to latex represents an immediate

anti-body mediated allergic response.
• TYPE IV HYPERSENSITIVITY REACTION: A more delayed
reaction, usually represents a reaction localized to the area of
skin contact, commonly called “allergic contact dermatitis”.

• allergic dermatitis may result due to the various chemicals like

• ammonia, thiurams, carbamates & mercaptobenzothiazoles
added as accelerators or antioxidants during the manufacture
of
latex based products.

49
• initial signs of allergic reaction among health care workers-
erythema on the backs of the hands & between the fingers.

• Once the dermatitis extends, the allergens will have access to

the bloodstream through the breaks in the epithelial layer
leading to an increased production of antibodies to the
allergen.

• patients typically develop circumoral erythema which is a type

IV reaction.

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 MANAGEMENT :

• In such cases, gloves made of vinyl, polyurethane & styrene

based rubbers, all of which are not vulcanized, should be
utilized.
• In an event of a severe type I reaction, administration
epinephrine is recommended.

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 METAL BASED ALLERGIC REACTIONS :

• The metal components of orthodontic appliances are generally

composed of 18/8 stainless steel (18% chromium and 8%
nickel).
• REFER TO IATROGENIC

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53
• Epilepsy is defined as two or more seizures that are not
provoked and are not due to acute disturbance of the brain ;it
is a sign of underlying brain dysfunction, rather than a single
disease.

ETIOLOGY :

In childhood: congenital abnormalities, birth related

complications, trauma, meningitis, encephalitis & malignancies.

In adulthood: brain tumours, cerebro-vascular disease, head

trauma & degenerative changes.

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• Description of Generalized Seizures
(LOC = loss of consciousness)
Type Manifestation
Tonic-clonic LOC with falling, 10-20 sec muscle rigidity
followed by 2-5 min clonic contractions of
muscles of extremities, head, trunk; urinary
and/or fecal incontinence, deep sleep 10-
30 min.
Atonic Brief loss of muscle tone with falling,
Clonic Alternating muscle contraction and
relaxation.
Tonic Persistent firm muscle contractions.

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 SIDE EFFECTSOF ANTIEPILEPTIC DRUGS

• gingival hyperplasia ( 50% of patients treated with phenytoin,sodium

valproate and ethosuximide).
• recurrent apthous-likeulcerations,
• gingivalbleeding,
• hypercementosis,
• root shortening,
• anomalous tooth development,
• delayed eruption and
• cervical lymphadenopathy.
 ORTHODONTICCONSIDERATIONS
• The appointment should be scheduled at mornings since patient is most
stress free
• Orthodontist must ensure that the patient has taken their normal anti-
leptic
(AEDs) medication, is not too tired before eachappointment.
• Gingival growth with phenytoin is widely known complication of
antiepileptic medication. Surgical removal of the hyperplastic gingiva is
advisable before starting the treatment. For patients with recurrent
hyperplasia, the patient’s physician should be contacted to discuss
alternative medication
• Stress, Light and sound can act as triggers, so always explain the procedure in
advance, perform as painlessly as possible and avoid direct operating light
on patient’s eyes.
 EPILEPTICEMERGENCIES

• Remain calm
• Remove all dental instruments and removable appliances from thepatient’s
vicinity
• Remove all tight clothings, tie, shoes, spectacles, rubberdametc
• Donot try to restrain the patient, instead try to remove all possible things
that could harm the patient
• Prevent tongue fall back and aspiration by tilting the patientsidewards
• In most cases seizure activity will last only upto 5 minutes. After
recovery, administer oxygen, amd keep the patient supine with legs
elevated.
• If the seizure activity lasts beyond 5 minutes it is imperative to seek
emergency help.
AUTOIMMUNEDISORDERS
 JUVENILE RHEUMATOIDARTHRITIS

• Juvenile rheumatoid arthritis Juvenile rheumatoid arthritis (JRA)is an

autoimmune inflammatory arthritis occurring before the age of 16 years.
• The process involves an inflammatory response of the capsule around the
joints secondary to swelling of synovial cells, excess synovial fluid, and the
development of fibrous tissue (pannus) in the synovium.
The pathology of the disease process often leads tothe destruction of
articular cartilage and ankylosis of thejoints.
• Temporomandibular joint (TMJ) can be damaged up to completebony
ankylosis.
 SIGNSANDSYMPTOMS

• RAtypically manifests with signs of inflammation, with the affected joints

being swollen, warm, painful and stiff, particularly early in the morning on
waking or following prolonged inactivity. Increased stiffness early in the
morning is often a prominent feature of the disease and typically lasts for
more than an hour. Gentle movements may relieve symptoms in earlystages
of the disease.
• Classic signs of rheumatic destruction of the TMJ include condylar flattening
and a large joint space
 ORTHODONTICCONSIDERATIONS
• It has been suggested by Klellberg that functional treatment for patients
with JRAwould prevent worsening of TMJ condition by reducing
mechanical loads resulting from stabilization of occlusion.
• On the other hand, Profitt states that functional appliances andheavy
class II elastics should be avoided in such cases as they Load the TMJ
• Orthopaedic chin cups should be avoided as they load the TMJ
• If the wrist joints are affected these patients have difficulty with tooth
brushing.
• Regular professional scaling
• Recommend use of an electric toothbrush
• Sugar-free medicines should be preferred to minimize caries.
64
• Diabetes is a metabolic disorder that effects 3%-4% of the
population.

• The disease is characterized by chronic hyperglycemia caused

by deficient insulin production.

• Persistently elevated blood glucose concentration gives rise to

acute & chronic complications with damage to various organs.

• Two main types of diabetes exist: type I being a total deficiency

of insulin & type II being a combination of resistance to insulin
& inadequate compensatory insulin secretion.

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GENERAL DESCRIPTION & MAIN CLINICAL FEATURES OF
DIABETES MELLITUS:

• hyperglycemia, polyuria, polydypsia, polyphagia & failure of

various organs.

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• ETIOLOGY :
• Several pathogenic processes may be involved in the
development of diabetes such as:
>Genetic defects

>Primary destruction of islet cells by inflammation, cancer,

surgery, and trauma.

>Iatrogenic after the admistration of

corticosteroids.

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 DIABETICPATIENTAND DENTALTREATMENT

• Identify diabetic patients –

• Xerostomia
• Candidiasis
• Glossopyrosis
• Recurrent oral infections
• Ketone breath
• Poor periodontal health
• Multiple carious teeth
Factors responsible for these oral
manifestations-

• Abnormal collagen metabolism

• Altered protein metabolism due to hyperglycemia
• Impaired neutrophil chemotaxis and macrophagefunction
 ORTHODONTIC CONSIDERATIONS

• Orthodontic treatment should be avoided in patients with poorly

controlled Insulin-dependent DM (HbA1c more than 9%), as these patients
are particularly susceptible to periodontal breakdown.
• It is important to stress good hygiene, especially when fixed appliancesare
used. Daily rinses with 2%chx mouthwash can provide further benefits.
• Diabetes related microangiopathy can occasionally occur in the periapical
vascular supply resulting in unexplained odontalgia, percussion
sensitivity, pulpitis or even loss of vitality. Orthodontist should be awareof
this phenomenon and periodical checkups are advised
• The most common dental office complication seen in diabetic patients
taking insulin is symptomatic low blood glucose or hypoglycemia. When
planning dental treatment, it is best to schedule appointments before or
after periods of peak insulin activity. Morning appointment ispreferable.
• If a patient is scheduled for a long treatment session e.g. about 90 minutes,
he or she should be advised to eat a usual meal and take the medication as
usual.
 MANAGEMENT OFHYPOGLYCEMICEPISODE
• Hypoglycemia occurs when blood sugar levels drop below 80 mg/dl and
typically becomes more acute in the 20-30 mg/dl range.
• Hypoglycemia can be prevented by making sure the insulin dependent
diabetic has eaten before treatment, by scheduling appointments in the
morning, and by having a glucose source readily available at chairside.
• If the patient exhibits signs and symptoms of hypoglycemia, administeran oral
carbohydrate such as regular cola, table sugar, or even a spoonful of honey or
icing to raise blood glucose levels.
• For a patient who becomes unconscious, maintain their airway, turn the
patient on their side to prevent aspiration and administer glucose in the
dependent cheek. This will usually provide sufficient glucose to allow the
patient to regain consciousness. The patient should then drink a liquidhigh in
sugar to increase their blood glucoselevel.
• keep the patient supine till completerecovery
 ACUTEADRENALINSUFFICIENCY

• Acute adrenal insufficiency (AAI) is a rare but severe condition caused by a

sudden defective production of adrenal steroids (cortisol and aldosterone). It
represents an emergency, thus the rapid recognition and prompt therapy are
critical for survival even before the diagnosis is made.

• The adrenaline is a neurotransmitter and a hormone that is secreted by the

medulla of the adrenal glands and mediate the FIGHTAND FLIGHT reaction to
stress.
• Acute adrenal insufficiency is associated with peripheral vascular collapse and
cardiac arrest along with severe bronchoconstriction. Therefore, the
orthodontist should be aware of the clinical manifestations and ways of
preventing acute adrenal insufficiency in patients.
 ORTHODONTICCONSIDERATIONS

• Orthodontic considerations Before treating a patient with a history

of steroid use, physician consultation is indicated to determine
whether the patient's proposed treatment plan suggest a
requirement for supplementalsteroids.
• Steroid coverage should be considered for minor oral surgery
procedures.
• Use of a stress reduction protocol and profound local anesthesia
may help to minimize the physical and psychologic stress associated
with therapy and reduce the risk of acute adrenal crisis.
• Hydrocortisone 200 mg (IV/ IM immediately pre-operatively or
orally 1 hour preoperatively) and continue normal dose of steroids
post-operatively.
74
• Osteoporosis is a common disease
characterized by reduced bone
mass, micro architectural
deterioration of bone tissue & an
increased risk of fracture.

• The prevalence of osteoporosis &

related fractures both increase in
age in women & men , reflecting an
age-related decline in bone mass.

• Clinical presentation is - fragility

fractures.

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• INVESTIGATIONS & DIAGNOSIS:

• Patients with suspected osteoporosis should undergo bone

densitometry at the spine & hip.

• It shows a BMD T-score of -2.5 or less at either side, the

diagnosis is confirmed.

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 MANAGEMENT :

• Bisphosphates are stable, synthetic analogues of

pyrophosphate that adsorb onto the bone surfaces & become
incorporated within the bone matrix beneath the resorbing
osteoclasts.

• When the bone that contains bisphosphates is ingested by

osteoclasts, the drug is released within the cell at high
concentration to cause osteoclast death. Thereby inhibiting
bone resorption.

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• HRT (HORMONE REPLACEMENT THERAPY (Estrogen)) is effective in
preventing post-menopausal bone-loss & long term treatment
reduces the risk of fracture.
• Calcium supplements(500-1000mg daily) slow down post-
menopausal bone loss, especially in women whose dietary
intake is low.
• Calcitonin prevents bone loss in post menopausal osteoporosis,
and is also effective in the secondary prevention of
osteoporotic vertebral fractures.

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• DRUG EFFECTS ON THE RESPONSE TO ORTHODONTIC FORCE :

• Two types of drugs are known to depress the response to

orthodontic force & may influence current treatment:
• Bisphosphates
• Prostaglandin inhibitors(eg indomethacin)

• Estrogen therapy (HRT)which is used frequently to prevent bone-loss

in older women, has little or no impact on orthodontic treatment.

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• But bisphosphonates,synthetic analogues of pyrophosphates ,
bind to hydroxyapatite crystals in the bone.

• They act as specific inhibitors of osteoclast mediated bone

resorption, so it is not surprising that the bone-remodeling
necessary in an older woman on this medication, will be
slower.

• If orthodontic treatment were necessary in an older lady taking

these medications, it would be worthwhile to explore with her
physician the possibility of switching to “EVISTA” temporarily.

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Kidney disorders

• Treatment involves- dietary restriction of salt

protein and potassium, dialysis and transplant of
kidney if required.
• The type of treatment that the patient is receiving
influences the type of orthodontic treatment.

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 ORTHODONTIC CONSIDERATIONS
Not dialysis dependent started only if the disease is well controlled and after the
physician’s consent

dialysis dependant- orthodontic treatment should be finished before kidney

transplant

received their kidney these patients are usually under immunosuppressant drugs
transplant- (cyclosporine, prednisolone etc). Thus these patients exhibit
severe gingival hyperplasia
Hyperplasia is maximum during the 1st 6 months of cyclosporine
therapy. Ortho treatment if possible, should be delayed

Gen consideration started only when oral hygiene is exemplary and must be
supplemented with 2% chlorhexidine.
Gingival growth to be removed
Removable appliance avoided

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 THE SPECIAL NEEDS CHILD

• In general “special needs” refers to those individuals

suffering from developmental disabilities (mental
retardation, attention deficit hyperactivity disorders,
dyslexia)
• Dependent on family
• Have increased chances of malocclusion but rarely receive
treatment.

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BENEFICIAL BUT NOT ESSENTIAL

• The pediatric dentist must treat a patient to eliminate dental

disease & relieve pain.

• At the same time the dentist is duty-bound to encourage

behavior alterations in both these areas.

• By contrast, orthodontics performed under these adverse

conditions is contraindicated.

• successful outcome is doubtful & iatrogenic damage in the

form of caries & gingival inflammation, is more likely.
• Thus, while treatment need is high & its object beneficial,
orthodontics is still considered to be “ELECTIVE”.
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THERAPEUTIC ACCESS :
Limited because
Uncontrolled limb & head movements & an inability to sit still.

• General behavior is often problematic because of reduced

understanding & increased apprehension, short attention span &
limited tolerance.

• Level of co-operation during treatment is usually significantly

impaired.

• Exaggerated gag reflex, apparently related to dental/medical phobia

• Excessive drooling.
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BEHAVIOUR MANAGEMENT & THE ORTHODONTIST:

• approach these patients with understanding ,compassion &

aim to gain their trust.

• They require more chairside time,

• an increased number of appointments,
• Furthermore, combining several procedures into a single
sedation or general anesthesia(GA) session requires the
availability of several professionals, for example pedodontist,
endodontist,oral surgeon & anesthesiologist, and this rarely
found in a private clinic, being usually achievable only in a
hospital setting.

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• It is essential to establish that, for most routine visits for
appliance adjustment, the use of behavior management
technique such as “tell, show & do” modification & positive
& negative reinforcement is adequate to achieve the goals
of respective visits.

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 GENERAL TREATMENT PRINCIPLES :

• The aim of the pretreatment visits is three-fold:

1> to raise the patient’s level of confidence in the
dental environment.
2>to assess the patient’s & parent’s compliance in
dental homecare.
3>to evaluate the expected degree of cooperation
that will finally be forthcoming.

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• Oral hygiene is perhaps the most crucial factor.

• Tooth brushing is not usually practiced by special needs

children (A lessened activity of the oral musculature, common
in several debilitating conditions & a lack of manual dexterity )

• The 1st step is to educate the parents and teach them the
correct way to brush the teeth.

• While the child may be prepared to improve their ways ,it must
be made clear to the parent that they must undertake the
overall responsibility of achieving a mouth that is both cleaned
regularly & inflammation-free.

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 SELECTING THE TREATMENT MODALITY :
• For those patients who have difficulties in communication & a
relative inability to co-operate, we can offer conscious
sedation, deep intravenous sedation or the use of general
anesthesia.

• It is to be noted that the main reason for the need of sedation

does not relate to pain, but rather to achieving a submissive or
motionless state in the patient, for an extended period of time.

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• The several different available methods of conscious sedation
have widened the scope for the orthodontist to provide
treatment in some the most resistant cases previously
considered “untreatable”. It may be elicited by the
administration of drugs through:
>INHALATION(nitrous oxide+oxygen)
>TRANSMUCOSALLY VIA NASAL DROPS
(Midazolam)
>ORALLY(chloral hydrate, diazepam, midazolam)
>INTRAVENOUSLY(propofol)

• It is particularly relevant to mention midazolam as a very

effective but short-acting conscious sedation agent.

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• The most suitable agent presently
used is propofol induction &
recovery are rapid & a safe level of
sedation is easily achieved, with
very few side effects.

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Simplifying orthodontic treatment
• Adjustment of removable appliances are made extraorally.
• From, the patient’s point of view maintenance of adequate
oral hygiene is more difficult with fixed appliances than with
removable appliances.

• Accordingly, it is recommended to extend the use of

removable appliances, with or without extra oral headgear
incorporated & limit the period of fixed appliance therapy.

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• Orthodontic appliances with a longer range of action, requiring
less frequent visits, are to be preferred.

• Becker & shapira found excellent acceptance & rapid results

with the full time wearing of removable, en-bloc integral
extraoral splint for the treatment of severe class II
malocclusions.

• This is simple to use, safe, requires fewer appointments.

• In extraction cases, correction of anteroposterior & vertical

discrepancies in the earlier part of the treatment with the same
extra oral removable maxillary orthopedic splint is
recommended. Proceeding to close the spaces with intra-arch
mechanics.

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• This protocol is preferred to limit or eliminate the use of
intermaxillary elastics, thereby relieving the parent or
homecare givers of the considerable responsibility.

• The use of a Tip Edge appliance versus other types of straight

wire brackets is advantageous because it permits the insertion
of heavier arch wires that are less likely to deform in the early
stages of treatment.

• Space closure is much more rapid since it is performed by

sliding mechanics in a broad slot, for any reason, treatment has
to stopped before its completion, more will have been
achieved.

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RELAPSE & RETENTION :

• within the special needs population, there are many subgroups

of children in whom the etiology may not be eliminated during
the treatment.

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• Thus, children with skeletal discrepancies, particularly the
vertical discrepancies as seen in congenital myopathies or with
large tongues, may never achieve stability.

• Removable retainers will hold the arch alignment of teeth

within the maxillary or mandibular arch, but cooperation
should be assured.

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• Where this may be in doubt, bonded lingual retainers are
preferred, even though this may involve a further sedation
session for its reliable placement.

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LIVERDISORDERS
 LIVERDISEASES
• Liver Diseases Liver diseases are very common and can be classified
as acute or chronic usually caused by
1. infection (hepatitis A, B, C, D, and Eviruses, infectious
mononucleosis),
2. injury,
3. exposure to drugs or toxic compounds,
4. an autoimmune process, or by a
5. 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.
 HEPATITISB

• 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.
• HBV, hepatitis Cvirus, 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.
 ORTHODONTICCONSIDERATIONS
•Infection control protocol should be followed according to the guidelinelaid
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 glutaldehyde or by spraying sodiumhypochlorite
and leaving it for 10min.
•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. 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 Bimmunoglobulin (0.6 ml/kg) should be administered
(preferably within 24 h) along with the vaccine series given at a differentsite.
•
•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 potentialto
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 medications metabolized
in the liver, such as acetaminophen, nonsteroidal anti-inflammatory agents.
 ACQUIREDIMMUNODEFICIENCYSYNDROME
• 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.

Exposure route Chance of infection

Blood transfusion 90%
Childbirth (to child) 25%[

Needle-sharing injection drug use 0.67%

Percutaneous needle stick 0.30%

 ORTHODONTICCONSIDERATIONS

• HIV 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.
• 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 ofdental
caries.
• Therefore, itis critical that the oral hygiene and health of children and
adolescents receiving ARVmedications be attended to daily.
• Percutaneous injuries and blood splashes to the eyes, nose or
mouthoccur 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
splashesto the eyes, nose or mouth were reported by oral
surgeons (1.8 peryear).
• Universal infection control procedures should be employed for all
patients irrespective of their health status. 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 alleviatexerostomia.
• 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 28days.
• PEPis available as either
• basic regimen (2 nucleoside reverse transcriptase inhibitor (NRTI)) or
• expanded regimen (2 NRTI and 1 Protease inhibitors (PI)drugs).
• NACO recommend zidovudine/stavudine + lamivudine (basic regimen)
and zidovudine + lamivudine + lopinavir/ritonavir.
OTHERS
 PREGNANCY
• not a contraindication for orthodontic treatment. Care should be taken to
minimize the potential exaggerated inflammatoryresponse related to
pregnancy-associated hormonal alterations. Meticulous plaque control and
oral hygiene should be maintained during treatment.
• Avoid X-rays or drug therapy and extractions particularly in the firstand
third trimester. The second trimester is the safest time to perform
extractions.
• Avoid supine position in late pregnancy. Supine hypotensive syndrome may
occur due to obstruction of the vena cava and aorta. This may result in
reduction in return cardiac blood supply with decreased placental perfusion;
this can be prevented by placing the patient on her left side or simply by
elevating the right hip 5 to 6 inches during treatment.
• Long, stressful appointments and surgical procedures should be avoided
• Analgesics, antibiotics, local anesthetics, and other drugs required during
pregnancy should be reviewed for potential adverse effects on the fetus.
 EHLERDANLOSSYNDROME

• Ehler danlos syndrome is an inherited disorder of the connective tissue. It is

characterised by extensive elasticity of the skin and laxity ofjoints.
• Skin in this syndrome is stretchable, velvet like readily bruisable and slow to
heal.
• Joints are hypermobile and dislocation is a recurring problem
• PROBLEMSWITH EDPATIENTS
• Tissue repair is abnormal
• Slow healing after extraction
• Problem in achieving proper cusp fossa relationship due to abnormal
tooth morphology
• 40% EDpatients show TMJ dislocation during treatment
 ORTHODONTICCONSIDERATIONS

• Appliance should be simple and smooth so that tongue and buccal

mucosa are not abraded
• Duration of retention must be longer because of added dental
mobility,slow
repair and poor organisation of collagen fibers of PDL
• Strict oral hygiene instructions must be given
• Abnormal or excessive pressure on the TMJ must be avoided to
prevent
subluxation.
 INFLUENCEOFDRUGSON ORTHODONTIC
TREATMENT

• ASPIRIN-
• It is a NSAID that blocks the cyclooxygenase pathway, thus inhibits the
prostaglandin synthesis. Prostaglandins are required for orthodontic tooth
movement Thus aspirin should be avoided in orthodontic patients

• BISPHOSPHONATES-
• It is a potent blocker of bone resorption it inhibits the formation and validity
of osteoclast. In experimental animals, bisphosphonates caused significant
dose-dependant reduction of tooth movement and inhibits relapse. Thus
bisphosphonates are beneficial in anchoring and retaining teeth during
orthodontic treatment
• CORTICOSTEROIDS-
• It is an anti-inflammatory and immunosuppressant drug. At low doses
(1mg/kg body wt) corticosteroids decrease orthodontic tooth movement by
suppressing osteoclastic activity .At high doses, (15 mg/ kg body wt)
cortcisteroids increases osteoclastic activity and produces significantly more
orthodontic tooth movement and subsequent relapse

• ALCOHOL
• Alcohol inhibits the hydroxylation of vitamin D in the liver and interfereswith
calcium metabolism, thus increases root resorption.

• CYCLOSPORINE
• It increases gingival hyperplasia. The greatest change occurs in the 1st 6
months Removable appliances, brackets, wires that imping on the gingiva and
dental calculus plaque and mouth-breathing aggravates gingival hyperplasia.
 CONCLUSION
• Since the long term survival of patients with medically compromised
conditions has become common place in the recent decades, the
orthodontist is bound to encounter them at some point in their
careers.

• And they seek orthodontic treatment to facilitate other dental

procedures necessary to control disease, restore function and/or
enhance appearance for better social acceptability.

• Hence, the orthodontist should be well equipped with an

armamentarium of not just appliances but also of sound knowledge &
behavioral management skills.

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