Orthodontic Treatment in Medically

Compromised
Presented by:
Dr. Pawan Gautam
Post Graduate Student

Under the guidance of:

Prof. Ashima Valiathan
B.D.S , D.D.S , M.S (U.S.A.)
Professor and Head
Director of Post Graduate Studies
Dept. of Orthodontics and Dentofacial Orthopedics
Manipal College of Dental Sciences ; Manipal.
Orthodontic Treatment in
Medically Compromised
 Introduction
 Orthodontics is a dynamic and exciting
specialty of dentistry. The nature of the
orthodontic patient base continues to evolve,
and the practicing orthodontist will be
increasingly challenged to assist in the
diagnosis and management of patients with
special medical needs.
 Given the age range of the majority of
orthodontic patients, it is important that the
orthodontist understand the basic management
of various medical disorders and specific
considerations in orthodontic treatment of
these patients. With an understanding of the
fundamental disease and the therapy for
medical problems, the orthodontist can be a
positive part of the health care team and
support a family in crisis.
 Medical conditions commonly encountered in
orthodontic patients include:
 risk of infective endocarditis;
 bleeding disorders;
 leukaemia:
 diabetes;
 cystic fibrosis;
 Infections
 juvenile rheumatoid arthritis;
 Diabetes Mellitus
 It is a clinical syndrome which produces an
excess of blood sugar, or hyperglycemia, due
to a deficiency or diminished effectiveness of
insulin.
 Type I Insulin dependent, sometimes termed
as Juvenile onset.
 Type II Insulin independent or maturity onset
 In addition there is diabetes of pregnancy
where a hormone, human placental lactogen
has a contra-insulin effect. Should this occur
the pregnant patient requires insulin therapy
during second and third trimester to be
discontinued as the placenta is removed.
 Diabetes- Complications
 Hyperglycemia & Ketoacidosis- Coma of slow
onset
 Hypoglycemia- coma of Sudden onset

 Concurrent complications
Diabetes of pregnancy- up to 9% death of
fetus.
Chronic complications: Vascular
 Macroangiopathy -Large blood vessels

 Head –Cerebrovascular accident (stroke)

 Heart -Angina Pectoris and myocardial

infarction
 Limbs-Gangrene
 Microangiopathy  Non-vascular
Small blood vessels of  Cataract
 Eyes -Blindness  Neuropathy
 Heart -Cardiomyopathy
 Kidneys-Renal failure
 Skin -Necrosis
 There is a great deal of evidence to show that
good diabetic control and the achievement of
normoglycemic state prevents many if not all
complications of the disease.
 Management involves diet control, insulin
therapy and oral hypoglycemic agents.
 Oral Manifestations

 Approximately half of the people with DM are

undiagnosed, and a dental examination might
give the first indication of the disease.
 Xerostomia, oral candidiasis, burning mouth
or tongue (glossopyrosis), impaired wound
healing, recurrent oral infections, and acetone
breath, multiple periodontal abscesses
 Several oral manifestations are associated with
DM, although they are mainly found in
patients whose DM is uncontrolled or poorly
controlled. Well-controlled patients without
local factors, such as subgingival calculus,
have as healthy a periodontium as
nondiabetics.
 Even well-controlled DM patients may have
more gingival inflammation, probably because
of impaired neutrophil function. Vascular
changes, such as DM-related
microangiopathies, have been shown to
encourage periodontal disease.
 Because periodontal disease tends to be more
common and more extensive in patients with
uncontrolled or poorly controlled DM, one
could hypothesize that normalizing the blood
glucose levels should stop the progression of
periodontal disease. This is, however, not true;
 Sastrowijoto et al (1990) demonstrated that
better metabolic control in type 1 patients did
not improve the clinical periodontal condition;
it ameliorates only when local oral hygiene
measures are used. The periodontal condition
will continue to deteriorate when the blood
glucose level is not well controlled.
 Dental/ Orthodontic treatment
 The key to any orthodontic treatment is good
medical control. Orthodontic treatment should
not be performed in a patient with uncontrolled
diabetes. If the patient is not in good metabolic
control every effort should be made to improve
blood glucose control. For DM patients with
good medical control, all dental procedures can
be performed without special precautions if
there are no complications of DM.
 However it is very important that the
procedure be completed without stress and
without causing the patient to miss a meal.
 The patient must be knowledgeable about the
disease, if on insulin must regularly determine
the blood glucose level, prior to the
appointment, must take the usual morning
dose of insulin or oral hypoglycemic and must
have a normal breakfast.
 The dentist must arrange an early appointment,
create as little stress as possible and have
emergency drugs readily available.
 Painless dentistry free of stress is required.
Topical anesthesia, aspirating syringe and
minimal epinephrine doses should be used.
Prilocaine plain (4%) or mepivacaine plain
(3%) are suitable solutions.
 If there is any difficulty in obtaining local
anesthesia then articaine 4%with 1/200 000
epinephrine using a minimal amount of
solution is acceptable.
 There is no treatment preference with regard to
fixed or removable appliances. It is important
to stress good oral hygiene, especially when
fixed appliances are used. These appliances
might give rise to increased plaque retention,
which could more easily cause tooth decay and
periodontal breakdown in these patients.
 Daily rinses with a fluoride-rich mouthrinse
can provide further preventive benefits.
Candida infections can occur, and then blood
glucose levels should be monitored to rule out
deterioration of the DM control.
 Diabetes-related microangiopathy can
occasionally occur in the periapical vascular
supply, resulting in unexplained odontalgia,
percussion sensitivity, pulpitis, or even loss of
vitality in sound teeth. Especially with
orthodontic treatment when forces are applied
to move teeth over a significant distance, the
practitioner should be alert to this phenomenon
and regularly check the vitality of the teeth
involved. It is advisable to apply light forces
and not to overload the teeth.
 Holtgrave and Donath (1989) studied
periodontal reactions to orthodontic forces.
They found retarded osseous regeneration,
weakening of the periodontal ligament, and
microangiopathies in the gingival area. They
concluded that the specific diabetic changes in
the periodontium are more pronounced after
orthodontic tooth movement.
 Diabetic coma
 Should a diabetic patient lose consciousness
during dental treatment the dentist is presented
with a life threatening emergency that requires
immediate treatment.
 The patient should be placed in a supine
position to rectify any syncope.
 If the diagnosis( hypo or hyperglycemia)
proves difficult then the patient should be
given a diagnostic i.v dose of glucose.
 This will not be harmful if it is a hyperglycemic
coma. However, if it is a hypoglycemic coma
the patient will improve and further oral
glucose can be given when as consciousness
returns.
 An unconscious patient with hyperglycemia
should be immediately transferred to the
hospital.
 Never give insulin to an undiagnosed patient in
coma as it may precipitate brain damage or
death if the patient is hypoglycemic.
 The best emergency drug is Glucagon 1 mg
which is far easier to administer as it can be
given subcutaneously, i.m or i.v. It takes 10
min for the drug to take effect during which
time the patient airway should be secured.
 Hypertension
 Hypertension is very common in the North
American population. The disease is usually a
result of increased peripheral resistance and
may result from either renal or non-renal
causes. Approximately two thirds of all cases
of hypertension are classified as "idiopathic or
essential hypertension." In these cases, the
etiology is not known.
 Patients with hypertension are treated with a
variety of medications. It has been stated that
there is "no particular best drug for the
treatment of high ,arterial pressure."
 Patients may be receiving antihypertensive
medication such as reserpine, methyldopa,
guanethidine or propanolol. These agents
have side affects of nausea and vomiting, as
well as xerostomia.
 Dental/Orthodontic Treatment
 The patients medical history may indicate
hypertension or should the patient not be
aware of the condition, the drug history should
alert the dentist.
 If a patient is on antihypertensive drugs, it is
important that the blood pressure be checked
to see if the hypertension is controlled.
 The degree of control of the patient's
hypertension ,and compliance with the
therapeutic regimen should be determined. As
these patients may have postural hypotension,
care should be taken when the patient rises
from the dental chair, particularly if the
procedure has been long and; lounge-type
chair is used. lf nitrous oxide is administered,
hypoxia should be avoided.
 For the known hypertensive on medication, the
diastolic pressure should be controlled at
90mm of Hg. A diastolic pressure over
100mmHg indicates hypertension or that the
patient is one who gives exaggerated response
to stress.
 Allow the patient to relax and rest in the dental
chair before repeating the blood pressure
reading. If the diastolic pressure remains high,
then carry out the emergency treatment only
and refer the patient to a physician. A
controlled hypertensive is at no greater risk
than a normal healthy patient.
 Local anesthesia solution containing weak
concentration of epinephrine are acceptable.
Gingival packing material containing
vasopressors should not be used.
 Acute hypertensive crisis
 Should the patient have an acute hypertensive
crisis, eg a blood pressure of 180/120 mmHg,
then terminate the procedure as the patient
requires immediate treatment. In such an
emergency the patient should be given
Nifedipine. The patient must bite the capsule
and slide it under the tongue where it is
absorbed in 5 min.
 In acute hypertensive crisis due to
phaeochromocytoma, the patient should be
referred directly to the care of physician.
 Leukemia
 Leukemias are a group of diseases that account
for one-third of all childhood malignancies.
Historically, leukemias were classified by the
cell of origin (lymphoid or myeloid) and by
the clinical course (acute or chronic). By using
current therapies, the course of leukemia is
generally chronic.
 Acute lymphoblastic leukemia (ALL) is the
single most common malignancy in children
(75% to 80% of childhood leukemias). Acute
lymphoblastic leukemia (ALL) is the result of
malignant transformation and clonal
proliferation of a single cell.
 The presenting features are caused by the
invasion of the bone marrow and organs with
malignant cells that crowd out the normal
functional hematopoietic elements. The patient
has fatigue, bone pain, fever, weight loss,
bleeding, malaise, and/or enlarged lymph
nodes. Definitive diagnosis is made by
analysis of the bone marrow (greater than 25%
lymphoblasts).
 Acute nonlymphocytic leukemia (ANLL)
accounts for 15% to 20% of childhood
leukemia. It results from malignant clonal
proliferation of a myeloid cell that infiltrates
the bone marrow and extramedullary tissues.
The clinical presentation is similar to that of
ALL with pallor, fatigue, infection, bleeding,
and bone pain. These patients may also exhibit
gingival hyperplasia.
 Chronic myelocytic leukemia (CML) accounts
for less than 5% of pediatric leukemia. Chronic
myelocytic leukemia (CML) is characterized
by myeloid hyperplasia of the bone marrow,
extramedullary hematopoiesis, and severe
leukocytosis. Bone marrow transplantation
offers the only hope for long-term survival.
 Lymphomas account for 10% of all childhood
malignancies with equal incidence of
Hodgkins and nonHodgkins types. Patients
present with fever, weight loss, anorexia, night
sweats, and itching. Excisional biopsy of
involved lymph nodes is performed for
diagnosis followed by bone marrow biopsy
and radiographic imaging studies for staging.
 NonHodgkins lymphomas (NHL) are malignant
neoplasms of the cells of the immune system.
Three subgroups are found: undifferentiated
lymphomas (47%), lymphoblastic (33%) large
cell, or histiocytic (16%). The NHL may arise in
any lymphoid tissue and numerous extra
lymphoid sites including bone, skin and the
orbits. Lymphadenopathy, weight loss, anorexia,
fever, and malaise are common at presentation.
 ROLE OF THE ORTHODONTIST

 Not all patients show intraoral signs of

hematologic malignancy. Although oral
symptoms do not play a major role in the
diagnosis of chronic leukemia, it has been
reported that between 12% and 17% of
patients with acute leukemia first sought
medical care because of an oral problem.
 Oral changes that should raise the
orthodontist's index of suspicion are gingival
oozing, petechiae, hematomas, ulcerations,
gingival pain, gingival hypertrophy, mucosal
pallor, pharyngitis, and lymphadenopathy.
Referral to a physician is indicated for patients
exhibiting these oral symptoms without
evidence of accompanying local causative
factors.
 Once a diagnosis of malignancy has been
made, the goal of the dental team, including
the orthodontist, is to prevent and to eliminate
oral infections for these patients. Patients
receiving chemotherapy have increased
predisposition to infection; infection is the
leading cause of death in
immunocompromised patients.
 Elimination of infectious foci that cause
septicemia is preferable to treatment for
infection. The prevalence of a probable or
possible oral origin of septicemia in the
immunosuppressed population has been
reported as 31%.
 It is difficult for an orthodontist to discontinue
treatment on a patient who is only part way
through orthodontic treatment and, in the early
stages of hematologic malignancy, may not be
exhibiting any oral symptoms. Chemotherapy
usually causes significant oral complications.
 Orthodontic appliances cause stress to the oral
mucosa and ulcerations may occur in reaction
to the slightest oral insult because the
neutropenia resulting from chemotherapy
impairs the regenerative capability of the
mucous membrane.
 Mucositis may progress from swelling,
soreness and whitening of the mucosa to
glossitis, cheilitis, and stomatis, which can be
so severe that morphine or meperidine is
required for palliation of pain. Candidiasis is
common. Oral infection by opportunistic
organisms may also occur. Xerostomia can be a
side effect from chemotherapy or the radiation
treatment given before bone marrow transplant.
 Patients and their families sometimes resist the
recommendation to terminate orthodontic
treatment. Ideally, there should be a joint
consultation among all the parties involved—
patient, parents, physician, family dentist, and
orthodontist—before discontinuing treatment
so that everyone is in agreement that what is
being done is in the best interest of the patient.
 It should be stressed that the orthodontist is not
"giving up" on the patient when halting
treatment. In situations with a good prognosis,
the emotional acceptance of appliance removal
may be enhanced by a careful selection of
words by the orthodontist.
 The appliance removal can be presented as a
transition point that divides the orthodontic
treatment into two distinct stages. The patient's
comfort and safety during all phases of
chemotherapy are enhanced if all fixed
appliances are removed. Removable retainers
should fit well so they do not become a source
of irritation, ulceration, and infection .
 Orthodontic treatment is an elective procedure
for most patients. For patients undergoing
treatment for hematologic malignancies, the risk
benefit balance is heavily weighted against
ongoing orthodontic treatment. Once a patient
has completed chemotherapy and is in long-term
remission, orthodontic treatment can be restarted
with the goal of achieving the originally planned
outcome of orthodontic treatment.
 Children with bleeding disorders

 Patients with mild bleeding disorders do not

usually present difficulties to the orthodontist.
However, those with severe bleeding disorders
can be more problematic. In addition to
haemophilia A (Factor VIII deficiency), which
affects about 1 in 10,000 males, a number of
congenital coagulation abnormalities caused
by deficiency of other clotting factors have
been recognized.
 As the prevalence of malocclusion in these
children is similar to the rest of the population
and the long-term outlook is good, orthodontic
treatment is often requested.
 Patients with haemophilia and related bleeding
disorders require special consideration in two
areas:
 Viral Infection risk
 Bleeding risk
 Viral Infection risk
 Factor concentrates are derived from human
blood donations. Since the mid- 1980’s
methods of manufacture have been developed
to remove hepatitis B, C and HIV from human
derived concentrates. However, the continued
use of concentrates, despite careful donor
selection and screening, and improved
methods of manufacture, still carries a small
risk of transmitting serious transfusion derived
viral infection.
 Most patients with moderate to severe
haemophilia A require Factor VIII concentrate
infusion before oral surgical procedures. The
recent introduction of genetically
manufactured Factor VIII products and their
current widespread use in affected children has
further reduced the risk of viral transmission in
this age group.
 Bleeding risk

 Generally, orthodontic treatment is not

contraindicated in children with bleeding
disorders. If tooth extraction or other surgery
is required in patients with severe bleeding
disorders they are usually hospitalized and
given transfusions of the missing clotting
factor in advance of the procedure. Whenever
possible non-extraction approach should be
adopted.
 Special Orthodontic considerations
1. It is desirable to prevent gingival bleeding
before it occurs. This is best achieved by
establishing and maintaining excellent oral
hygiene.
2. Chronic irritation from an orthodontic
appliance may cause bleeding and special
efforts should be made to avoid any form of
gingival or mucosal irritation.
3. Archwires should be secured with elastomeric
modules, rather than wire ligatures which carry
the risk of cutting the mucosal surface. Special
care is required to avoid mucosal cuts when
placing and removing archwires.
4. The duration of orthodontic treatment for any
patient with a bleeding disorder should be
given careful consideration. The longer the
duration of treatment the greater the potential
for complications. (Van Venrooy, Proffit 1985)
Children with juvenile rheumatoid arthritis

 Juvenile Rheumatoid Arthritis (J RA) is an

inflammatory arthritis occurring before the age
of 16 years and now embraces Stills disease
(Grundy et al 1993). Although uncommon
compared with adult rheumatoid arthritis, at its
worst, JRA is considerably more severe than
the adult disease and leads to gross deformity.
 One form of this disease which affects girls in
late childhood may involve virtually any joint
and is associated with rheumatoid nodules,
mild fever, anaemia, and malaise (Scully and
Cawson, 1987). Damage to the
temporomandibular joint (TMJ) has been
described, including complete bony ankylosis.
 It has been suggested that restricted growth of
the mandible resulting in a severe Class II jaw
discrepancy occurs in 10-30 per cent of
subjects with JRA (Wallon et al., 1999).
Classic signs of rheumatoid destruction of the
TMJ include condylar flattening and a large
joint space.
 Special Orthodontic considerations
 1.If the wrist joints are affected these patients can
have difficulty with tooth brushing. They may
require additional support from a hygienist during
their orthodontic treatment and the use of an
electric toothbrush should be considered.
 2. Some authors have suggested that orthodontic
procedures that place stress on the TMJs, such as
functional appliances and heavy Class II elastics,
should be avoided if there is rheumatoid
involvement of the TMJs (Proffit, 1991).
 Instead, consideration should he given to using
headgear to treat children with rheumatoid
arthritis who have moderate mandibular
deficiency. However, others feel that
functional appliances may unload the affected
condyle and act as a ‘joint-protector’
(Kjellberg et al., 1995).
 3. It has been suggested that in cases of severe
mandibular deficiency mandibular surgery
should be avoided, and a more conservative
approach using maxillary surgery and
genioplasty should be considered (van
Venrooy and Proffit 1985)
 Children with cystic fibrosis
 Cystic fibrosis is an autosomal recessive
disorder of the exocrine glands. It is the
commonest inherited disease among
Caucasians with an incidence of one in 2500
live births (Jaffe and Bush, 1999). The main
clinical manifestations of cystic fibrosis relate
to changes in the mucous glands of the
pulmonary and digestive systems. Males and
females are equally affected.
 The lungs are invariably involved and there is a
non-productive cough that leads to acute
respiratory infection, bronchopneumonia,
bronchiectasis, and lung abscesses. The disease
pursues a relentless course and, until recently,
the life expectancy was not much more than the
second decade. Heart and lung transplants have
proved successful in a small group of patients
with respiratory failure (Grundy et al,. 1993).
 The current median survival for subjects with
cystic fibrosis is 30 years (Jaffe and Bush, 1999).
 Orthodontic considerations

 Before contemplating orthodontic treatment

for patients with cystic fibrosis the patient's
physician should be contacted to determine the
severity of the problem and the likely
prognosis.
 General anaesthesia should usually be avoided
and any orthodontic extractions should be
delayed until an age when extraction under
local anaesthesia is feasible. Local anaesthesia
combined with inhalation sedation has an
important role to play in the management of
these children.
 It has been suggested that for the majority of
these children only limited orthodontic
treatment should be contemplated (Grundy et
al., 1993). However, life expectancy varies
and orthodontic management will depend on
the general prognosis of each individual case.
 It should also be remembered that salivary
glands, particularly the submandibular glands
are often affected by cystic fibrosis. Salivary
volume can be reduced and there may be an
increased risk of decalcification during
orthodontic treatment, due to changes in saliva
or dietary alterations (van Venrooy and Proffit,
1985). Appropriate preventive measures must
be instigated from the outset including dietary
advice and daily fluoride mouthrinses.
 Endocarditis
 Endocarditis is a life-threatening disease,
although it is relatively uncommon.
Substantial morbidity and mortality can result
from this infection despite advances in
antimicrobial therapy. Primary prevention of
endocarditis is therefore very important
(Dajani et al 1997).
 High risk-endocarditis Prophylaxis
recommended (Dajani et al., 1997)
 Individuals at high risk of developing severe
endocardial infection include those with
prosthetic cardiac valves, previous bacterial
endocarditis, complex cyanotic congenital
heart disease (Fallot's tetralogy), or surgically
constructed systemic pulmonary shunts or
conduits.
 Moderate risk-endocarditis; prophylaxis
recommended (Dajani et al., 1997)
 Includes most other congenital cardiac
malformations, acquired valvular dysfunction
(rheumatic heart disease), hypertrophic
cardiomyopathy, and mitral valve prolapse
with regurgitation.
 Negligible risk-endocarditis prophylaxis NOT
recommended (Dajani et al., 1997)
 This category includes cardiac conditions in
which the development of endocarditis is not
higher than in the general population. This list
includes isolated secundum, atrial septal defect,
surgical repair of atrial or ventricular septal
defects, or patent ductus arteriosus, previous
coronary artery bypass graft, mitral valve
prolapse without valvular regurgitation, innocent
heart murmurs, previous Kawasaki disease or
rheumatic fever without valvular dysfunction,
cardiac pacemakers, and implanted defibrillators.
 Orthodontic procedures requiring
antibiotic prophylaxis
 In the United Kingdom the British Society
for Antimicrobial Chemotherapy (Simmons et
al 1991) recommend the use of antibiotic
prophylaxis before the following dental
procedures: extractions, scaling, ,and surgery
involving the gingival tissues.
 The American Heart Association
recommendations state that antibiotic
prophylaxis should be given at the initial
placement of orthodontic bands, but not
orthodontic brackets (Dajani et al 1997).
 Prophylaxis regimen for dental, oral
respiratory tract, or esophageal procedures
 Standard general prophylaxis
 Amoxicillin Adult 2g; children 50mg/kg
orally 1 hr before the procedure
 Unable to take oral medication
 Ampicillin Adult 2g i.m or i.v; children
50mg/kg i.m or i.v within 30 min before the
procedure
 Allergic to penicillin
 Clindamycin Adult 60mg; children 20mg/kg
orally 1hr before the procedure
 Cephalexin Adult 2 g; children 50mg/kg
orally 1hr before the procedure
 Azithromycin or clarithromycin Adult
600mg; children 20mg/kg orally within 30 min
before the procedure
 Allergic to penicillin and Unable to take oral
medication
 Clindamycin Adult 600mg; children 20mg/kg
i.v within 30 min before the procedure
 Cefazolin Adult 1g; children 25mg/kg i.v or
i.m within 30 min before the procedure
 Orthodontic procedures causes
bacteremia?
 Digling (1972) failed to detect any bacteraemias
when fitting or removing orthodontic bands for
10 patients. However, McLaughlin et al (1996)
reported bacteraemias in three (10 per cent) out
of 30 patients when molar hands were fitted.
 More recently a study among 40 patients
reported a lower prevalence of bacteraemia or
7.5 per cent in initial banding (Erverdi et al
1999).
 In a separate study of bacteraemia at
debanding and debonding the same authors
detectcd bactememias in 6.6 per cent of the 30
patients studied (Erverdi et al, 2000).
 Orthodontic considerations
 The orthodontist has to make a decision on a
case by case approach in agreement with the
patient's cardiologist. The risk of endocarditis
must be weighed against the risk of an adverse
reaction to the antimicrobial therapy prescribed.
 I. As an initial step the level of risk of
endocarditis occurring must be established. This
will involve contacting the patient's cardiologist,
although the American Heart Association
guidelines offer guidance on the risk categories
of various heart defects (Dajani et al. 1997).
 Orthodontic treatment should never be
commenced until the patient has exemplary
oral hygiene and excellent dental health. The
prevalence and magnitude of bacteraemias of
oral origin are directly proportional to the
degree of oral inflammation and infection
(Pallasch and Slots 1996). Guntheroth (1984)
highlighted the fact that most bacteraemias
occur as a result of mastication, tooth brushing,
or randomly as a result of oral sepsis.
 In a review of the orthodontic treatment of
patients at risk from infective endocarditis, it
has been suggested that prior to any
orthodontic procedure a 0.2 percent
chlorhexidine mouthwash should be used
(Khurana and Martin, 1999).
 If possible, the orthodontist should avoid using
orthodontic bands and instead, use bonded
attachments. Antibiotic prophylaxis is
considered unnecessary when bonding
brackets or adjusting orthodontic appliances.
 If banding is necessary the orthodontist must
decide if antibiotic prophylaxis is required.
 This decision should be based on the risk of
endocarditis represented by the patient's heart
defect (high or moderate risk) and the patient's
dental health. Two recent studies have found a
relatively low prevalence of bactcraemia
during orthodontic banding (McLaughlin et al.
1996; Erverdi et al, 1999).
 Prior to giving antibiotic prophylaxis it is
important to establish that no known penicillin
allergy exists,
 The latest American guidelines recommend
the use of antibiotic prophylaxis for initial
banding. but not when removing bands (Dajani
et al.. 1997). It could be argued that the risk of
bacteraemia might be higher at band removal
when the gingival tissues adjacent to the bands
are often inflamed.
 Erverdi et al. (2000) found a low prevalence of
bacteraemia at debanding (6.6 per cent), but
patients with poor oral hygiene were
specifically excluded from their study. Plainly,
it would be prudent to consider using
antibiotic prophylaxis if the gingivae adjacent
to the orthodontic bands are inflamed and the
patient has a high-risk cardiac lesion.
 Hepatitis
 In recent years the prevalence of Hepatitis has
increased markedly. At the same time, many
new diagnostic techniques have been
developed permitting a very accurate
determination of the active and carrier states of
the disease.
 The etiologic agents of viral hepatitis are
currently recognized as atleast three distinct
viruses: HepatitisA, Hepatiti.s B, and “non A-
nonB” Hepatitis. There is considerable overlap
in the clinical presentation of infection with
the various viral agents.
 Hepatitis A has been traditionally called
"infectious hepatitis". The main route of
transmission is via a fecal/oral route. An attack
is thought to confer lifetime immunity and the
carrier state is almost nonexistent. The
diagnosis of Hepatitis is made on clinical basis,
although certain immunologic markers have
been reported.
 For example, there is an increased IgM in recent
infection and an increased IgG in old infections
 Hepatitis B has been traditionally called "serum
hepatitis". Although parentral transmission has
been the classical route for Hepatitis B, non-
parentral infection via saliva, urine, feces and
semen are now known to be significant factors
in the transmission of this disease.
 Approximately 5 to 10 % of the patients
develop a carrier state and continue to have
high level of Hepatitis B surface antigen. The
diagnosis or Hepatitis B is via three markers:
Hepatitis B surface antigen, Hepatitis B surface
antibody and Hepatitis core antibody.
 Dental considerations
 The dental treatment of the patient with
Hepatitis requires careful planning. If the patient
has active hepatitis, only palliative care should
be given until the disease is under control. For
patients with a history of hepatitis, dentists must
determine, prior to therapy, the type of hepatitis,
and the carrier state of the patient. If the patient
has active hepatitis and requires emergency
treatment or is a carrier of the virus, strict
aseptic technique must be practiced.
 It is essential that a rubber dam be used and
that efforts be taken to minimize aerosols.
Some authorities recommend that high speed
drills not be used and the ultrasonic
prophylaxis units be avoided. All instruments
should be debrided immediately following use,
and sterilization of instruments and handpieces
is important.
 Universal precautions gloves, mouth masks
and eye glasses should be worn.
 The room should be disinfected following
treatment of the patient. Center for
Communicable Disease of the U.S. Public
Health Service has suggested that thorough
mechanical debridement of all instruments is
the most important step in preventing the
spread of Hepatitis.
 Tuberculosis
 Presently, tuberculosis is mainly a disease of
drug abusers, HIV infected patients and
disadvantaged people. Less frequently,
tuberculosis occurs in older subjects
debilitated by chronic diseases or malignancy
or immunosuppressant treatment.
 Mycobacterium tuberculosis is the agent of
tuberculosis. The bacilli spread through
lymphatic and blood vessels to any organ.
 In immunocompromised patients, as a rule, the
infection is followed by the disease, which
shows severe course and frequent
extrapulmonary involvement.
 Dental Considerations
 Most antitubercular drugs are metabolised in
liver, and they can cause liver toxicity with
coagulation abnormalities. Rifampin may
cause leukopenia and thrombocytopenia as
well as a noticeable discoloration of body
fluids.
Acetaminophen is not recommended in a patient
on isoniazid to avoid liver toxicity.
Acetylsalicylic acid is not recommended in
patients on streptomycin to avoid ototoxicity.
Any antitubercular drugs can cause skin
reaction, which potentially can involve the oral
mucosa.
 Dental treatment should be postponed in any
patient with active or suspected active
pulmonary tuberculosis. Such patients must
receive a complete medical assessment to rule
out tuberculosis. An extreme barrier protection
(gloves, gowns, masks, goggles, eye protection
and face shields) is indicated during
emergency dental treatment of patients with
suspected or active pulmonary tuberculosis.
 After treatment of such a patient, the dental
health workers should be started on
prophylaxis for tuberculosis based on M.
tuberculosis susceptibility test.
 HIV and related infections
 HIV type 1 and type 2 are retroviruses that
cause progressive immunologic dysfunction
complicated by opportunistic diseases
resulting in the Acquired immunodeficiency
syndrome (AIDS).
 HIV transmission is similar to Hepatitis B: it is
usually by sexual, parentral and vertical
transmission. Hepatitis B is much more
virulent however.
 There is a 0.3 % risk of HIV infection after a
stick with contaminated material from a
documented HIV infected patient. This risk of
HIV infection is 0.1% if the mucosal
membrane or abraded skin is exposed to the
contaminated material.
 Dental considerations
 Universal precautions should be followed.
 HIV infected patients receive multiple
medications including drugs for HIV infection,
prophylaxis, opportunistic diseases and many
concurrent disorders. Side effects and drug
interactions are a major concern.
 Ritonavir, for example, is contraindicated in
combination with 24 other drugs because of
interaction.
 HIV infected patients with advanced disease
have high risk for skin reaction to common
antibiotics, including trimethoprim-
sulfamethoxazol, amoxicillin-clavulanic acid,
ciprofloxacin, clindamycin and many others.
 Pregnancy
 The pregnant patient requires special
considerations in the planning and executing
of dental treatment. Preventive dentistry
should be emphasized, both by the dentist and
the physician throughout the patient's
pregnancy.
 The dentist should exercise discretion in the
use of radiographs in dental treatment. Only
those films considered absolutely necessary
for proper dental care should be taken. With
modern technique, including filtration,
collimation of the beam, and the use of a lead
apron for the patient, gonadal radiation should
be below the measurable level.
 Similarly, medication prescribed for the
patient should be minimal. Drugs which have
been shown to be non-teratogenic by long
clinical experience are preferable to newer
medications.
 If antibiotics are required, penicillin or
erythromycin should be prescribed. Sedatives
and hypnotics should generally be avoided, as
many of these have been shown to be
teratogenic. Prior to prescribing any
medication, the dentist should familiarize
himself with possible teratogenic effects of the
agent and should consult with patient’s
obstetrician.
 Careful treatment planning is necessary for
dental care during pregnancy. In general, the
second trimester is the best time for therapy.
At this time the fetus is more developed than
in the first trimester and the patient is more
comfortable.. The danger of premature uterine
contraction is less than during the third
trimester.
 The supine hypotensive syndrome has been
described in patients with a gravid utrerus, and
it is important to have the patient rise slowly
from the dental chair so as to avoid syncope.
 Elective procedures are best done in
immediate postpartum period and should be
scheduled appropriately.
 Oral complications of pregnancy have been
described.
 Pregnancy gingivitis is a recognized
phenomenon and is probably related to
hormonal abnormalities and to a decreased
attention to gingival hygiene by the pregnant
women. Pregnancy tumors, an exuberant
response of the gingival epithelium to
inflammation, have also been reported. These
lesions may regress following delivery, but if
they do not they should be excised.
Neurologic and Psychiatric concerns
 Seizures
 Epilepsy is not a specific disease, but a
symptom of a brain abnormality which
manifests as chronic often recurrent
paroxysmal discharge of many neurons.
 Treatable seizures include hypoglycemia, drug
or alcohol withdrawal, local anesthesia
overdose, stroke, vascular malformation, brain
abscess and brain tumors.
 The dentist/orthodontist needs to be aware of
any medications and seizure history to be
prepared to face the possibility of a seizure and
to know the natural history of patients
condition.
 The more serious complication of epilepsy is
status epilepticus. It may lead to hyperpyrexia
and acidosis, ultimately causing death. This
complication is a variant of grand mal activity
in which the seizures continue unabated for
more than 5 min or in which two or more
seizures occur consecutively without any
intervening period of consciousness.
 Management of the epileptic patient in the
dental office includes three concepts:
comprehensive knowledge of the patients
seizure history and medications, and avoidance
of situations likely to provoke a seizure and
ability to treat the seizure (manage the acute
situation).
 A dentist should also know the medications,
dosages, serum level compared to therapeutic
level, compliance of the patient, and whether
or not the seizure activity is fully controlled.
 Seizure disorders must be under control before
any complex dental procedure is begun. A
dentist/orthodontist should also be aware of
the potential side effects of anti convulsant
medication, mainly gingival hyperplasia.
(Phenytoin)
 Management of seizure

 If the patient does develop a seizure in the

office, the following steps should be taken:
 Terminate dental therapy and remove all
instruments from the mouth.
 Position the patient supine on the floor , if
unconscious.
 Protect the patient from injury by removing
him or her from proximity to sharp edges,
possibility of a fall, or other trauma. Loosen
tight collar and other clothing.
 Observe the patient. Lightly strain if needed,
and be prepared to assist in maintenance of the
airway if needed. Supplemental oxygen may
be necessary.
 Most seizures are self limited. The patient can
be monitored, then discharged home in the
care of an adult if the patient has a history of
general seizures, which are characteristic. The
patient should not drive.
 There are two cases in which the patient
cannot be sent home after a seizure:
 1. If this is the first seizure for this patient or
the first relapse after a seizure free period of
medication.
 2. if status epilepticus has occurred.
 In the latter case, immediate transfer to a
hospital is mandatory for prompt treatment.
 Syncope

 Syncope, a transient loss of consciousness,

may be caused by cardiovascular, neurologic,
metabolic, or psychological disorders as well
as iatrogenic events.
 Severe anxiety, however, may produce a near
syncopal or even true syncopal episode that
quickly resolves with local treatment.
 Vasodepressor syncope is heralded by
significant changes in the depth or rate of
respiration, pallor, complaints of feeling ill and
nauseated, diaphoresis, decreased pulse and
blood pressure.
 Patient at risk includes anxious individuals as
well as patients with systemic illness that
predisposes them to hypoglycemia, chest pain
or shortness of breath.
 It is important to treat the presyncopal patient
to prevent loss of consciousness, which
indicates 50 -70 % decrease in blood flow to
the brain. Once the patient has enough
decrease in blood flow to the brain, the
possibility of greater morbidity increases.
 The first step is to stop all dental procedures,
to remove all objects from the mouth, and to
reposition the patient as to facilitate blood
return to the heart and thus better circulation to
the brain.
 This last position is accomplished by adjusting
the Trendelenburg position in the supine
position to allow the legs to be above the level
of heart and, for the pregnant patient, by
adjusting the pillow to ensure that the patient
is lying on one side.
 A pregnant patient requires frequent
repositioning during the procedure to avoid
compression of the inferior vena cava by the
uterus, thus ensuring adequate venous return.
 Xerostomia
 Xerostomia may be managed initially by
stimulating salivary gland function. The use of
saliva substitutes should only be considered
when gland function cannot be stimulated.
Furthermore, when gland function cannot be
improved, complications such as dental caries
and mucosal, salivary and periodontal
infections must be prevented and controlled.
 Stimulation of Saliva Production

 In patients with drug-induced xerostomia,

changing the prescribed medication(s) may
accomplish some improvement in saliva
production. In others, salivary gland function
may be stimulated mechanically, by taste
stimuli, or by drugs. Sugar-free gum or
candies are useful stimuli. Drugs that may be
effective include cholinergic agents.
 Pilocarpine, given as ophthalmic drop placed
intra-orally, is effective in doses of up to five mg
administered three times daily. Anetholetrithione
(Sialor), which acts by increasing the number
and concentration of the salivary gland receptor
sites for neurostimuli, can increase saliva
production in xerostomic patients, unless there is
such advanced dysfunction that the gland has
virtually ceased to produce saliva.
 Before sialogogues are prescribed, it is
important that the possible drug interactions
and side-effects are understood. For example,
pilocarpine has the potential to cause adverse
effects on cardiovascular , pulmonary and
gastrointestinal function. In the case of Sialor,
the principal complication is that of
gastrointestinal upset.
 Symptomatic Management

 Several saliva substitutes or mouth-wetting

agents are now marketed. Most contain
carboxymethylcellulose, although there are
some that contain animal mucins, and some
also contain constituents that may facilitate the
remineralisation of enamel. While some
patients find these products useful, clinical
experience suggests that they are not always
well accepted.
 Xerostomia patients should be given dietary
instruction, cautioning them against foods that
contain sugar, alcohol, caffeine or spices
(which worsen the xerostomia or irritate the
mucosa) to reduce the risk of caries and
candidiasis.
 Drug induced reactions
 Previous studies have shown that the severity
of cyclosporine-induced gingival enlargement
is related, at least in part, to the presence of
chronic external stimuli, such as plaque and
mouth breathing. Irritation from orthodontic
appliances would potentiate this form of
gingival hyperplasia. Furthermore,
cyclosporine-induced gingival hyperplasia has
been observed to counteract or complicate
orthodontic therapy.
 The enlarged gingiva grows over the ends of
the buccal or lingual tubes, occluding their
lumina; springs impinge on bulbous interdental
papillae instead of the intended tooth; loops in
arch wires are pushed outward, altering the
direction of intended force; and the embrasures
where various types of retention clasps of
removable appliances fit are filled with
hyperplastic gingivae, preventing proper
seating and retention of the appliance.
 Daley et al (1991) showed that another
complicating factor associated with
cyclosporine is the finding that cyclosporine-
induced gingival hyperplasia prevented the
eruption of at least some of the teeth in almost
5% of the patients. An operculectomy may be
necessary to treat this problem.
 This study also indicated that orthodontic
treatment of the cyclosporine-treated patient
may significantly increase gingival
enlargement as a result of direct contact of
orthodontic apparatuses with the gingivae. It
seems reasonable, therefore, to reduce this
contact whenever possible in an attempt to
control the hyperplasia. The following
guidelines are suggested:
 Whenever possible, brackets, bands, wires,
elastics, springs, and loops should be designed
to avoid any contact, however small, with any
part of the gingivae. Reduced bracket heights
and small brackets are recommended.
Whenever possible, fixed appliances should be
limited to brackets only, and cemented bands
should be avoided. Similarly, cemented
retainers such as arch bars should not contact
the interdental papillae.
 All tubes, springs, loops, brackets, and bands
should be removed as soon as possible after
their purpose is fulfilled.
 3. The use of removable appliances should be
avoided if at all possible. The retention clasps
for these appliances fit into interdental
embrasures resulting in localized gingival
enlargement, and the gingivae adjacent to the
acrylic may exhibit generalized enlargement in
adolescents. There is a high risk that
appliances will fail to fit, resulting in the need
for sequential appliances to accommodate the
alterations in the gingivae.
 If possible, delay orthodontic treatment until
the patient has been on cyclosporine therapy
for at least 6 months. The greatest change in
the gingivae occurs in the first 6 months of
cyclosporine therapy in most patients. The
delay will give the orthodontist a better idea of
the patient's gingival response to the drug and
the degree of complication to expect in
orthodontic therapy.
 Dental plaque formation should be controlled
by meticulous oral hygiene.
 Learning Disability
 Discrimination of any type against any
individual with a disability, regardless of the
nature or severity of the disability, is morally,
ethically and legally indefensible, since
persons with Downs syndrome and other
developmental disabilities have equal human
rights (Pueschel,1989).
 WHY ORTHODONTICS?
 It all comes down to the basic question: “Do we
believe that persons with disabilities need
functional and esthetic considerations comparable
to that of ‘normal’ persons?” The reality is that
the youngster with mental retardation grows
older, periodontal disease is an increased
possibility with a maloccluded dentition. Severe
esthetic malocclusions can compromise already
difficult social relationships and potential
employment opportunities.
 All too often children with Mental Retardation
may have primary and secondary dentition
difficulties resulting from the following: (1)
untoward habit development (including finger
sucking, mouth breathing, tongue thrusting),
(2) the absence of a diet that includes rough
and course foods that require thorough
chewing, (3) increased levels of caries, and (4)
the loss of teeth and space maintenance.
 In addition, malocclusions may have
developed as a consequence of prenatal or
postnatal trauma, hereditary factors, or general
poor muscle development. It may have been
“convenient” to approach the situation with the
view that behavioral management
complications precluded interceptive
orthodontic services.
 Factors related to mastication, including
swallowing patterns, food pocketing, bruxism,
drooling, and other problems associated with
neuromuscular control, may present further
difficulties. A higher incidence of traumatic
injuries also is prevalent in patients with
special needs as a result of problems of
ambulating and possible seizure activity.
 Frequently patients with special needs take
multiple medications, the side effects of which
can affect adversely the oral health. Seizure
medications can cause gingival hyperplasia.
Psychotrophic and cardiovascular medications
can cause dry mouth. The high sugar content
in medications for children can contribute to
dental decay.
 The population of children and adolescents
with special needs exhibits a higher percentage
of malocclusions than the normal population.
This is related to more frequent occurrences of
craniofacial deformities, abnormal growth and
development, and a higher incidence of
abnormal tongue posture and orofacial
muscular disturbances.
 Orthodontic considerations

 Jackson (1967) felt that children with learning

disability should not be discounted merely
because an ‘ideal’ orthodontic result was not
possible. For these patients, the aims of
orthodontic treatment may need to be modified
from ‘ideal’ but orthodontic treatment may
offer an aesthetic improvement and hence
enhanced social acceptance.
 Hausdorff (1980) recommended that
orthodontic treatment of the mentally retarded
should be on a selective basis and that, to be
successful, appliance therapy must be adapted
to the needs of the specific patient. The use of
a multiband appliance with light wires was
found to be the most effective appliance and
the use of removable appliances was not
recommended.
 Close co-operation between the providers of
routine care for these patients and the
orthodontist is essential for their clinical
management. If a general anaesthetic is
thought appropriate for dental treatment, then
placement of an orthodontic appliance can be
carried out at the same time as any necessary
extractions, restorative or periodontal
treatment.
 A very high standard of moisture control can
be achieved under a general anaesthetic; in
fact, the conditions for bonding are excellent
and a high standard of bracket and band
placement is possible. The extractions are
carried out following bonding of the brackets,
but before placement of archwires.
 Patients with learning disability frequently
have anterior teeth which have been
traumatized and it is advisable, if there is any
doubt about bonding these teeth, to place
bands anteriorly. If this procedure is followed,
this group of patients are no more prone to
breakages compared with a group of patients
undergoing routine fixed appliance therapy.
 Routine orthodontic visits for adjustment of
appliances should be kept short and archwire
changes kept to a minimum. As far as possible,
treatment is carried out using round wires and
tipping mechanics. Tip-Edge brackets have
been found to be particularly useful.
 However, some patients find they are able to
tolerate more complex fixed appliance therapy
once the appliances have been placed. During
orthodontic treatment some patients become
more tolerant during adjustment appointments,
but equally there are those whose behavior
deteriorates.
 So long as the appliance is being well tolerated
and the oral hygiene is satisfactory then the
fixed appliance is used for retention. A period
of 6 months retention with the fixed, followed
by fixed bonded retainers is recommended for
this group, as removable retainers are usually
poorly tolerated.
 Bonded retainers for the upper labial segment
are particularly useful, but in some cases this
may be complicated by previous trauma and
restorative treatment to the upper labial
segment teeth. Occasionally, crown and bridge
work can complement permanent retention.
 But when dealing with patients with any
disability, the need is for practitioners (and the
general public) to recognize the wide
variations in the abilities of individuals.
 For example, the single notation of “mental
retardation” (with no further description) in a
medical history form offers little to no
guidance for practitioner-staff-patient-family
communication, treatment planning, and home
care follow-up.
 In addition, individuals with mental retardation
may not comprehend the need for oral
hygiene. Individuals with physical disabilities
may lack the dexterity to accomplish the
needed oral hygiene.
 Basically, the need is to create an awareness in
the practicing orthodontic community of the
increasing need for treatment of patients with
mental retardation; successful treatment plans
could then follow.
 One approach emphasizes a series of important
steps including the following:
• The parents/guardians are made fully
responsible for the oral hygiene, caries
prevention prophylaxis, and appliance care.
• The use of behavior modification for
particularly difficult procedures.
• Redesigning appliances that are less patient-
reliant and more patient-resistant.
 In addition to standard orthodontic treatment
plans, services for patients with disabilities
may require steps to improve nasal breathing,
sucking ability, chewing, swallowing, speech,
and orofacial functioning. Therapeutic
exercises that do not require conscious
cooperation may need to be instituted in a
working relationship with myofunctional
therapists.
 Root resorption in Medically
compromised
 According to Becks, endocrine problems
including hypothyroidism, hypopituitarism,
hyperpituitarism, and other diseases are related
to root resorption. This hypothesis, based on
basal metabolic rates, has not been examined
by updated blood analyses.
 Hyperparathyroidism, hypophosphatemia, and
Paget’s disease have been linked to root
resorption in a few anecdotal case reports. It
has been suggested that hormonal imbalance
does not cause but influences the phenomenon.
 A controlled animal study (Engstrom 1988)
did not support the hypothesis that secondary
hyperparathyroidism is primarily responsible
for increased root resorption. A further study
(Goldie 1984) suggested that the parathyroid
hormone plays a major role in bone
metabolism, but that low calcium levels are
necessary for root resorption to occur. Calcium
ions are reputed to play an important role in
mediating the effects of external stimuli (force,
hormones) on their target cells.
 Nutrition. Marshall (1929)advocated that
malnutrition can cause root resorption. Becks
(1936)demonstrated root resorption in animals
deprived of dietary calcium and vitamin D. It
was later suggested that nutritional imbalance
is not a major factor in root resorption during
orthodontic treatment.(1983)
 Controversial results were reported when a
low calcium diet was fed to rats undergoing
active orthodontic treatment. (Engstrom 1988)
 Mc Nab et al 1999 (AJODO) determined if
asthmatic patients exhibited a higher incidence
or severity of external apical root resorption
compared with healthy patients after fixed
orthodontic treatment. Records were obtained
from patients treated with fixed appliances; 99
were healthy and 44 had asthma.
 A 4-grade ordinal scale was used to determine
the degree of external apical root resorption.
Combined tooth analysis showed that
asthmatics had significantly more external
apical root resorption of posterior teeth after
treatment compared with the healthy group (P
=.0194).
 Tooth-by-tooth analysis (adjusted for
treatment time, appliance, extractions,
headgear, overbite, overjet, sex, and age at
start of treatment) found the upper first molars
were most susceptible to external apical root
resorption. Although the incidence of external
apical root resorption was elevated in the
asthma group, both asthmatics and healthy
patients exhibited similar amounts of grade 2
(moderate) and grade 3 (severe) resorption.
 Nishioka M (Angle Orthod 2006) determined
whether there is an association between
excessive root resorption and immune system
factors in a sample of Japanese orthodontic
patients. The records of 60 orthodontic patients
(18 males, age 17.7 +/- 5.7 years; 42 females,
age 16.4 +/- 6.0 years) and 60 pair-matched
controls (18 males, age 15.9 +/- 4.5 years; 42
females, age 18.5 +/- 5.2 years) based on age,
sex, treatment duration, and the type of
malocclusion were reviewed retrospectively.
 The pretreatment records revealed that the
incidence of allergy and root morphology
abnormality was significantly higher in the
root resorption group (P = .030 and .001)
 The incidence of asthma also tended to be
higher in the root resorption group. From these
results, it was concluded that allergy, root
morphology abnormality, and asthma may be
high-risk factors for the development of
excessive root resorption during orthodontic
tooth movement in Japanese patients.
 Conclusion
 The medically compromised patient seeking
oral health care presents a special problem for
the dentist. Medication received by the patient
or the disease process itself may require
modification of the dental treatment plan.
 The provision of comprehensive health care
will require the collaborative efforts of the
physician and the dentist.
 Adjunctive and comprehensive orthodontic
treatment is feasible for medically
compromised individuals if proper precautions
are taken.
 Correction of malocclusion makes it possible
to improve the esthetics and quality of
periodontal tissues, in addition to providing
psychosocial benefits.
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