MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS IN ORTHODONTICS
precise knowledge of management of medically compromised patients in any dental practice is a must, to avoid any unforeseen complication. this presentation deals with the commonly encountered medical situations and their management.
• Infective endocarditis (IE) is a disease in which microorganisms
colonize the damaged endocardium or heart valves.
• The organisms most commonly encountered in IE are alpha -hemolytic
streptococci (e.g., Streptococ-cus viridans). However, nonstreptococcal
organisms often found in the periodontal pocket have been
increasingly implicated, including Eikenella corrodens, Actinobacillus
actinomycetemcomitans, Capnocytophaga, and Lactoba-cillus species.
HOW IS ORTHODONTICS RELATED TO INFECTIVE
• Most bacteraemia arises from everyday activities such as chewing and
tooth brushing. (guntheroth 1894)
• The bacteraemia experienced by the patient maybe increased by
plaque accumulation, which increases in the presence of orthodontic
• The prevalence and magnitude of bacteraemia of oral origin are
directly proportional to the degree of oral inflammation
present.(pallasch and slots 1996)
• Degling (1972) failed to detect any bacteremia while manipulating
• McLaughlin et al 1996 reported bacteremia in 10% patients while
fitting orthodontic bands
• Contact the patient’s cardiologist to asses the risk
• Start the treatment only when the patient exhibits exemplary oral hygiene
• 0.2% chlorhexidine 5 min before the orthodontic procedure (khurana and
• Avoid bands. Use bonded attachments when possible
• Regular supportive therapy from a hygienist
WHICH PROCEDURES NEEDS PROPHYLAXIS?
• American Heart Association (AHA) recommends that antibiotic
prophylaxis should be given, in all cardiac patients with the highest
risk of IE mentioned before, in all dental procedures that involve
manipulation of gingival tissue or the periapical region of teeth or
perforation of the oral mucosa (dajani et al 1997)
• These include probing, extractions, banding procedures (both band
placement and band removal) and placement of separators. They do
not recommend prophylaxis at the placement of removable
orthodontic appliances, adjustment of orthodontic appliances,
placement of orthodontic brackets, and bleeding from trauma to the
lips or oral mucosa.
• Resources from British National Formulary suggest supplementation of
antibiotic prophylaxis for dental procedures with chlorhexidine
gluconate gel 1% or chlorhexidine gluconate mouthwash 0.2%, used 5
min before procedure. It is also recommended to continue antibiotic
prophylaxis two days after the dental procedures
• Diabetes mellitus, or simply diabetes, is a group of metabolic diseases in which a
person has high blood sugar, either because the pancreas does not produce
enough insulin, or because cells do not respond to the insulin that is produced.
• This high blood sugar produces the classical symptoms of polyuria (frequent
urination), polydipsia (increased thirst), and polyphagia (increased hunger).
There are three main types of diabetes mellitus
• Type 1 DM results from the body's failure to produce insulin, and
currently requires the person to inject insulin or wear an insulin pump.
This form was previously referred to as "insulin-dependent diabetes
mellitus" (IDDM) or "juvenile diabetes".
• Type 2 DM results from insulin resistance, a condition in which cells fail
to use insulin properly, This form was previously referred to as non
insulin-dependent diabetes mellitus (NIDDM) or "adult-onset diabetes".
• The third main form, gestational diabetes, occurs when pregnant
women without a previous diagnosis of diabetes develop a high blood
glucose level. It may precede development of type 2 DM.
Factors responsible for these oral manifestations-
• Abnormal collagen metabolism
• Altered protein metabolism due to hyperglycemia
• Impaired neutrophil chemotaxis and macrophage function
• 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 appliances are
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 aware of
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 is preferable.
• 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
MANAGEMENT OF HYPOGLYCEMIC EPISODE
• 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, administer an 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 liquid high in
sugar to increase their blood glucose level.
• keep the patient supine till complete recovery
ACUTE ADRENAL INSUFFICIENCY
• The adrenaline is a neurotransmitter and a hormone that is secreted by the
medulla of the adrenal glands and mediate the FIGHT AND FLIGHT reaction to
• 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.
• 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 supplemental steroids.
• 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.
• Asthma is a diffuse chronic inflammatory obstructive lung disease with
episodes of chest tightness that causes breathlessness, coughing, and
wheezing all of which are related to bronchiole inflammation. It is
associated with hyper reactivity of the airways to a variety of stimuli
and a high degree of reversibility of the obstructive process.
• Typical oral health conditions in asthma:
Greater rate of caries development than do their non-asthmatic
counterparts because of anti-asthmatic drugs-induced xerostomia.
The use of nebulized corticosteroids can result in throat irritation,
dysphonia and dryness of mouth, oropharyngeal candidiasis and,
rarely, tongue enlargement.
In an asthmatic patient, the common mouth breathing habit and
immunological factors will cause gingival inflammation.
• Review the medical history
• As a rule in general, elective orthodontics should be performed only on
asthmatic patients who are asymptomatic or whose symptoms are well
• appointment should be in the late morning or the late afternoon.
• Orthodontist needs to be aware of the potential for dental materials and
products to exacerbate asthma. These items include dentifrices, fissure
sealants, tooth enamel dust (during interproximal slicing) and methyl
methacrylate. Therefore, fixed appliances and bonded retainers without
acrylic are preferable.
• Dental local anesthetics with vasoconstrictors should be used with caution in
asthmatic patients, as many vasoconstrictors contain sodium metabisulfite, a
preservative that is highly allergenic.
• Anxiety is a known ‘asthma trigger', so the orthodontist should reduce the
stress level of the patient.
• Oxygen and bronchodilator should be available during treatment.
• It has been found that improper positioning of suction tips, fluoride
trays or cotton rolls could trigger a hyper reactive airway response in
sensitive subjects. Eliciting a coughing reflex should be avoided.
• Prolonged supine positioning, bacteria-laden aerosols from plaque or
carious lesions and ultrasonically nebulized water can provoke asthma
triggers in the dental setting.
• Avoid rubber dam use
• Owing to chances of allergy, offending NSAIDs include ketorolac,
ibuprofen and naproxen sodium should be avoided after banding and
bonding. In such cases, choice of analgesic is acetaminophen.
ACUTE ASTHAMATIC ATTACK
In case of acute attack, following steps should be taken.
• •Discontinue the procedure and allow the patient to assume a
• •Maintain a patent airway and administer bronchodilator via
• •Administer oxygen via face-mask. If no improvement is observed and
symptoms are worsening, administer epinephrine subcutaneously
(1:1,000 solution, 0.01 milligram/kilogram of body weight to a
maximum dose of 0.3 mg)
• •Alert emergency medical services. Maintain a good oxygen level until
the patient stops wheezing and/or medical assistance arrives
• the most serious and rare form of latex allergy,
• Type I hypersensitivity can cause an immediate and potentially life-threatening
IgE mediated reaction (angeodema, utricria).
• Involves a delayed skin rash with blistering and oozing of the skin.
• May extend beyond the area of contact of irritant
Irritant contact dermatitis
• Contact dermatitis causes dry, itchy, irritated areas on the skin, most
often on the hands.
• Anaphylactic shock can be provoked in allergic persons by
the previous use of latex in an area: latex is typically powdered to
prevent sticking, latex proteins become attached to the particles of
powder, and the powder becomes airborne when the latex item is
used, triggering potentially life-threatening Type I reactions when the
latex-contaminated powder is inhaled by susceptible persons.
• Avoid contact with the product and use of alternative products made
of synthetic rubber or plastic
• Substitute with alternative ones made of other components such as
nitrile, neoprene, vinyl, polyurethane, and styrene-based rubbers
• The use of powder-free gloves will diminish the amount of
• Early morning appointments can reduce patient exposure to airborne
natural rubber latex particles
• Administration of pretreatment antihistamines
• In the event of a severe type I reaction, emergency procedures such
as administration of epinephrine are recommended ( i.e. EpiPen®)
• Use of latex free products during treatment
• Nickel typically elicits contact dermatitis, which is a Type IV delayed
hypersensitivity immune response.
• Kerosuo et al found the prevalence of nickel allergy in Finnish
adolescents to be 30 per cent in girls and 3 per cent in boys.
• It has been suggested that a threshold concentration of approximately
30 ppm of nickel may be sufficient to elicit a cytotoxic response.
• Release rate for full mouth orthodontic appliances is 40
micrograms/day for nickel.
COMMON CLINICAL FINDINGS
Dermal reactions reported included
redness, irritation, itching eczema,
soreness, fissuring, and desquamation
most often attributed to a metal extraoral
(eg, headgear facebow) component of the
Intraoral reactions included redness,
swelling, itching and soreness of the lips
and oral mucosa, and inflammation of the
• In confirmed cases of nickel allergy, NiTi wires should be replaced with SS/
TMA/fiber reinforced composite wires
• If allergy continues even after substituting the wires, fixed treatment should
be discontinued and plastic aligners should wherever possible
• Epilepsy is defined as two or more seizures that are not provoked and are not
due to an acute disturbance of the brain; it is a sign of underlying brain
dysfunction, rather than a single disease. There are many different types of
epilepsy; treatment and prognosis varies by type.
CLASSIFICATION OF EPILEPSY
I Focal seizures (Older term: partial seizures)
A Simple partial seizures – consciousness is not impaired
B Complex partial seizures – consciousness is impaired (Older terms:
temporal lobe or psychomotor seizures)
C Partial seizures evolving to secondarily generalized seizures
II Generalized seizures
A Absence seizures (Older term: petit mal)
1 Typical absence seizures
2 Atypical absence seizures
B Myoclonic seizures
C Clonic seizures
D Tonic seizures,
E Tonic–clonic seizures (Older term: grand mal)
F Atonic seizures
III Unclassified epileptic seizures
SIDE EFFECTS OF ANTIEPILEPTIC DRUGS
• gingival hyperplasia ( 50% of patients treated with phenytoin, sodium
valproate and ethosuximide).
• recurrent apthous-like ulcerations,
• gingival bleeding,
• root shortening,
• anomalous tooth development,
• delayed eruption and
• cervical lymphadenopathy.
• The appointment should be scheduled at mornings since patient is most stress
• Orthodontist must ensure that the patient has taken their normal anti-leptic
(AEDs) medication, is not too tired before each appointment.
• 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
• Removable appliances are to be used cautiously as they can get dislodged
during a seizure.
• Space closing mechanics including nickel titanium closing springs, elastomeric
power chain or active elastics can impinge on the hyperplastic gingival tissue.
Therefore, they are not used in these patients.
• Small low profile brackets are recommended . Bands are avoided .
• Essix based retainers should be relieved around the gingival margins to
maintain alignment. Bonded retainers are avoided in patients at risk of gingival
• Remain calm
• Remove all dental instruments and removable appliances from the patient’s
• Remove all tight clothings, tie, shoes, spectacles, rubberdam etc
• 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 patient sidewards
• 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
JUVENILE RHEUMATOID ARTHRITIS
• Juvenile rheumatoid arthritis Juvenile rheumatoid arthritis (JRA) is an
autoimmune inflammatory arthritis occurring before the age of 16
• 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 to the destruction of
articular cartilage and ankylosis of the joints.
• Temporomandibular joint (TMJ) can be damaged up to complete bony
SIGNS AND SYMPTOMS
• RA typically 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 early stages
of the disease.
• Classic signs of rheumatic destruction of the TMJ include condylar flattening
and a large joint space
• It has been suggested by Klellberg that functional treatment for patients
with JRA would prevent worsening of TMJ condition by reducing
mechanical loads resulting from stabilization of occlusion.
• On the other hand, Profitt states that functional appliances and heavy
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
• Regular professional scaling
• Recommend use of an electric toothbrush
• Sugar-free medicines should be preferred to minimize caries.
The main inherited coagulation disorders include hemophilias A and B and von
• Haemophilia A is a recessive X-linked genetic disorder involving a lack of functional
clotting Factor VIII and represents 80% of haemophilia cases.
• Haemophilia B is a recessive X-linked genetic disorder involving a lack of functional
clotting Factor IX. It comprises approximately 20% of haemophilia cases.
• Two main areas to be considered in treatment of these patients are
• Chances of iatrogenic viral infections
• Risk of spontaneous bleeding
CHANCES OF IATROGENIC VIRAL INFECTION
• Medical treatment of choice in bleeding disorders is administration of
various factor concentrates. Transfusion of these concentrates derived
from human blood may spread viral infections like hepatitis B, C and HIV.
The recent introduction of genetically manufactured factor VIII products
has reduced this risk.
RISK OF BLEEDING DURING EXTRACTION.
• To prevent surgical haemorrhage, factor VIII levels of at least 30% are
• Parenteral I-deamino-8-D-arginine vasopressin (DDAVP) can be used to
raise factor VIII levels 2- to 3-fold in patients with mild or moderate
• Wherever possible a nonsurgical approach should be adopted.
• Excellent oral hygiene is must for preventing gingival bleeding before it occurs.
Every effort should be made to avoid any chronic irritation from orthodontic
• Arch wires should be secured with elastomeric modules rather than wire
ligatures, which carry the risk of cutting the mucosal surfaces. Special care is
required when placing and removing arch wires.
• Preformed bands should be preferred to avoid unnecessary trauma
• In case of prolonged gingival oozing, 25% zinc chloride can be used. It causes
shrinkage and cauterisation of the tissue.
• In painful conditions, aspirin should be avoided (pg inhibition) instead
acetaminophen or acetaminophen in combination with codeine can be
• Bleeding can be managed by replacement of missing clotting factors, so
extractions and orthognathic surgery is not contraindicated if managed
• More than 40% paediatric malignancies are hematological either leukemia or
• Oropharyngeal lesion can be the initial signs in 10% of acute leukemia.
• In the absence of local causative factors, orthodontist should be suspicious of
patients who present with gingival redness pain or hypertrophy, pharyngitis
and lymphadenopathy. In such cases prompt referral to a physician is
necessary to exclude malignancy.
• Orthodontic treatment may start or resume after completion of all medical
therapy and after at least 2-year event free survival when risk of relapse has
been decreased and patient is not on immunosuppressive drugs.
• Patient's physician should be consulted before starting the procedure.
• Those receiving chemotherapy have an increased potential for infection that is
the leading cause of morbidity in immune compromised patients. Thus it is
imperative to take extreme aseptic measures.
• To counter xerostomia during cancer therapy use of sugar free chewing gum,
candy, saliva substitutes, frequent sipping of water, and/or moisturizers is
• Developing dental tissues are particularly sensitive to radiation. Careful
consideration should be given to the patients having severe root shortening,
dilacerations etc while planning the tratment
• Chronic renal failure may be due to a variety of cause which leads to loss of
kidney function. Treatment involves- dietary restrictiom 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
• Those who are not dot dialysis dependant- orthodontic treatment must be
started only if the disease is well controlled and after the physician’s consent
• Those who are dialysis dependant- orthodontic treatment should be finished
before kidney transplant
• Those who have received their kidney transplant-
• For prevention of graft rejection, these patients are usually under
immunosuppressant drugs (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
• Orthodontic treatment should be started only when oral hygiene is
exemplary and must be supplemented with 2% chlorhexidine.
• If gingival growth is present, it must be removed surgically before
commencement of orthodontic treatment
• Removable appliances should be avoided as they may fail to fit owing to
• Liver Diseases Liver diseases are very common and can be classified as acute
or chronic usually caused by infection (hepatitis A, B, C, D, and E viruses,
infectious mononucleosis), injury, exposure to drugs or toxic compounds, an
autoimmune process, or by a genetic defect.
• The liver has a broad range of functions in maintaining homeostasis and
health: it synthesizes most essential serum proteins (albumin, transporter
proteins, blood coagulation factors V, VII, IX and X, prothrombin, and
fibrinogen. Liver dysfunction alters the metabolism of carbohydrates, lipids,
proteins, drugs, bilirubin, and hormones.
• 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 C virus, and hepatitis D virus are blood borne and can be
transmitted via contaminated sharps and droplet infection.
• aerosols generated by dental hand pieces could infect skin, oral mucous
membrane, eyes or respiratory passages of dental personnel.
• The main orthodontic procedures to result in aerosol generation are removal
of enamel during interproximal stripping, removal of residual cement after
debonding, and prophylaxis.
•Infection control protocol should be followed according to the guideline laid
down by occupational safety and health administration
All members of the team should be immunized against HBV. Barrier technique
such as gloves, eye glasses, and mouth mask should be used.
•HBV can survive on innate subjects for 7 days. Impressions can be one of the
links in transmitting the HBV to orthodontics. The impressions must be
disinfected by dipping them in glutaldehyde or by spraying sodium hypochlorite
and leaving it for 10 min.
•Post-exposure prophylaxis for HBV infection should be given to those who are
exposed percutaneously or through mucus membrane to blood or body fluids of
known or suspected. If the source individual is Hepatitis B surface antigen
(HBsAg) positive and the exposed person is unvaccinated or antibody level is less
than 10 mIU/ml, hepatitis B immunoglobulin (0.6 ml/kg) should be administered
(preferably within 24 h) along with the vaccine series given at a different site.
•Liver disease can result in depressed plasma levels of coagulation factors. If
extraction is required, special attention should be paid as the risk of bleeding
increases; an infusion of fresh frozen plasma may be indicated.
Advanced oral surgical procedures or any dental procedures with the potential to
cause bleeding performed on a patient with multiple or a severe single
coagulopathy may need to be provided in a hospital setting
• Care should be taken when prescribing any medication for patients with liver
disease. Hepatic impairment can lead to failure of metabolism of some drugs and
result in toxicity. Caution should be used in prescribing medications metabolized
in the liver, such as acetaminophen, nonsteroidal anti-inflammatory agents.
ACQUIRED IMMUNODEFICIENCY SYNDROME
• AIDS is an infectious disease caused by the HIV, and is characterized by
profound immunosuppression that leads to opportunistic infections,
secondary neoplasm and neurologic manifestations.
• Oral manifestations are common and may represent early clinical signs of the
disease, often preceding systemic manifestations. This aspect is particularly
important as dentists may be responsible for early detection of oral lesions
which may indicate HIV infection.
Exposure route Chance of infection
Blood transfusion 90%
Childbirth (to child) 25%[
Needle-sharing injection drug use 0.67%
Percutaneous needle stick 0.30%
• 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
• Many antiretoviral medications (ARV) can cause nausea and vomiting.
Frequent episodes of vomiting can affect the oral cavity by increasing acid
levels in the saliva and soft tissues. As a result, the oral flora may change due
to the overgrowth of bacteria that are not susceptible to acid. This overgrowth
can lead to oral conditions such as candidiasis and an increased rate of dental
• Therefore, it is critical that the oral hygiene and health of children and
adolescents receiving ARV medications be attended to daily.
• Percutaneous injuries and blood splashes to the eyes, nose or mouth occur
frequently during orthodontic treatment.
• On average, dentists in Canada report 3 percutaneous injuries and 1.5
mucous-membrane exposures per year.
• The highest frequencies of percutaneous injuries were reported by
orthodontists (4.9 per year) and the highest frequencies of blood splashes to
the eyes, nose or mouth were reported by oral surgeons (1.8 per year).
• Universal infection control procedures should be employed for all patients
irrespective of their health status. Patients must also be stimulated to use
additional auxiliary procedures such as antiseptic mouthwashes
• Xerostomia has been observed in pediatric patients. Clinicians should
recommend sugarless gum and frequent consumption of water or highly
diluted fruit juices to alleviate xerostomia.
• Post-exposure prophylaxis (PEP) should be given immediately after the
accidental occurrence. PEP for HIV exposure is best when started within
golden period of <2 h and there is little benefit after 72 h. The prophylaxis
needs to be continued for 28 days.
• PEP is available as either
• basic regimen (2 nucleoside reverse transcriptase inhibitor (NRTI)) or
• expanded regimen (2 NRTI and 1 Protease inhibitors (PI) drugs).
• NACO recommend zidovudine/stavudine + lamivudine (basic regimen)
and zidovudine + lamivudine + lopinavir/ritonavir.
• Pregnancy as such is not a contraindication for orthodontic treatment. Care
should be taken to minimize the potential exaggerated inflammatory response
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 first and 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.
EHLER DANLOS SYNDROME
• Ehler danlos syndrome is an inherited disorder of the connective tissue. It is
characterised by extensive elasticity of the skin and laxity of joints.
• Skin in this syndrome is stretchable, velvet like readily bruisable and slow to
• Joints are hypermobile and dislocation is a recurring problem
• PROBLEMS WITH ED PATIENTS
• Tissue repair is abnormal
• Slow healing after extraction
• Problem in achieving proper cusp fossa relationship due to abnormal
• 40% ED patients show TMJ dislocation during treatment
• Appliance should be simple and smooth so that tongue and buccal mucosa are
• 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
INFLUENCE OF DRUGS ON ORTHODONTIC
• 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
• 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
• 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 inhibits the hydroxylation of vitamin D in the liver and interferes with
calcium metabolism, thus increases root resorption.
• 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.
• An orthodontist needs to recognize various medical conditions and their
impact on treatment procedures. Treatment should where appropriate be
postponed until the medical problem is in remission or the side effects of the
drug therapy are minimized. Comprehensive treatment may not always
benefit the patient. Treatment procedure should be modified according to
need. Consent before treatment, Good patient cooperation and constant
monitoring of the progress of the treatment are necessary to minimize
physical damage and to maximize treatment outcome.
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