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ORTHODONTIC 
CONSIDERATIONS IN 
MEDICALLY COMPROMISED 
PATIENTS 
BY-DR 
JASMINE ARNEJA 
MDS II YEAR
CONTENTS 
• Introduction 
• Definition 
• Infective endocarditis 
• Metabolic disorders 
• Diabetes 
• Adrenal insufficiency 
• Hematological disorders 
• Bleeding tendencies 
• Malignancies 
• Autiommine 
• Juvenile rheumatoid arthiitis
• Resiratory disease 
• Asthma 
• Allergies 
• Latex 
• Nickel 
• Nervous system disorders 
• Epilepsy 
• Liver disorders 
• Immunocompromised states 
• Others 
• Effect of drugs on orthodontic treatment 
• Conclusion 
• reference
INFECTIVE ENDOCARDITIS
INFECTIVE ENDOCARDITIS 
• 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 
ENDOCARDITIS? 
• 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 
appliances. 
• 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 
orthodontic bands 
• McLaughlin et al 1996 reported bacteremia in 10% patients while 
fitting orthodontic bands
MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS IN ORTHODONTICS
WHO IS AT RISK?
ORTHODONTIC CONSIDERATIONS 
• Contact the patient’s cardiologist to asses the risk 
• Start the treatment only when the patient exhibits exemplary oral hygiene 
habits 
• 0.2% chlorhexidine 5 min before the orthodontic procedure (khurana and 
martin 1999) 
• 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
MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS IN ORTHODONTICS
METABOLIC DISORDERS
DIABETES 
• 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.
DIABETIC PATIENT AND DENTAL TREATMENT 
• 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 macrophage function
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 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 
usual.
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 
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.
ORTHODONTIC CONSIDERATIONS 
• 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.
RESPIRATORY DISORDERS
ASTHMA 
• 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.
ORTHODONTIC CONSIDERATIONS 
Before treatment: 
• 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 
controlled. 
• 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.
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 
comfortable position. 
• •Maintain a patent airway and administer bronchodilator via 
inhaler/nebulizer. 
• •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
HYPERSENSITIVITY REACTIONS
LATEX ALLERGIES 
Type I 
• 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). 
Type IV 
• 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.
ORTHODONTIC MANAGEMENT 
• 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 
aerosolized allergens 
• 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
LATEX FREE PRODUCTS
NICKEL ALLERGY 
• 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 
appliances 
Intraoral reactions included redness, 
swelling, itching and soreness of the lips 
and oral mucosa, and inflammation of the 
gingival tissues
ORTHODONTIC MANAGEMENT 
• 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
NERVOUS SYSTEM DISORDERS
EPILEPSY 
• 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, 
• hypercementosis, 
• root shortening, 
• anomalous tooth development, 
• delayed eruption and 
• cervical lymphadenopathy.
ORTHODONTIC CONSIDERATIONS 
• 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 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 
patient’s eyes.
• 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 
overgrowth
EPILEPTIC EMERGENCIES 
• Remain calm 
• Remove all dental instruments and removable appliances from the patient’s 
vicinity 
• 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 
emergency help.
AUTOIMMUNE DISORDERS
JUVENILE RHEUMATOID ARTHRITIS 
• 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 to the destruction of 
articular cartilage and ankylosis of the joints. 
• Temporomandibular joint (TMJ) can be damaged up to complete bony 
ankylosis.
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
MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS IN ORTHODONTICS
MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS IN ORTHODONTICS
ORTHODONTIC CONSIDERATIONS 
• 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 
brushing. 
• Regular professional scaling 
• Recommend use of an electric toothbrush 
• Sugar-free medicines should be preferred to minimize caries.
HAEMATOLOGICAL DISORDERS
BLEEDING DISORDERS 
The main inherited coagulation disorders include hemophilias A and B and von 
Willebrand's disease. 
• 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 
needed. 
• 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 
haemophilia. 
• Wherever possible a nonsurgical approach should be adopted.
ORTHODONTIC CONSIDERATION 
• Excellent oral hygiene is must for preventing gingival bleeding before it occurs. 
Every effort should be made to avoid any chronic irritation from orthodontic 
appliance. 
• 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 
prescribed 
• Bleeding can be managed by replacement of missing clotting factors, so 
extractions and orthognathic surgery is not contraindicated if managed 
carefully
HAEMATOLOGICAL MALIGNANCIES
• More than 40% paediatric malignancies are hematological either leukemia or 
lymphoma. 
• 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 CONSIDERATIONS 
• 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 
recommended. 
• 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
RENAL FAILURE
RENAL FAILURE 
• 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 
orthodontic treatment.
ORTHODONTIC CONSIDERATIONS 
• 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 
hyperplastic gingiva
LIVER DISORDERS
LIVER DISEASES 
• 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 
• 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.
ORTHODONTIC CONSIDERATIONS 
•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%
ORTHODONTIC CONSIDERATIONS 
• 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 of dental 
caries. 
• 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.
OTHERS
PREGNANCY 
• 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 
heal. 
• 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 
tooth morphology 
• 40% ED patients show TMJ dislocation during treatment
ORTHODONTIC CONSIDERATIONS 
• 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.
INFLUENCE OF DRUGS ON 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 interferes with 
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 
• 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.
REFERENCES 
• Burden D, Mullally B, Sandler J. Orthodontic treatment of patients with 
medical disorders. 
Eur J Orthod. 2001 Aug;23(4):363-72. 
• Parnell AG. The medically compromised patient. Int Dent J. 1986 Jun;36(2):77- 
82. 
• Singaraju G, Vannala v. Management Of The Medically Compromised Cases In 
Orthodontic Practice . Asian Journal of Medical Sciences 1 (2010) 68-74 
• Smrat ER, Macloid RL, Laerence CM: Allergic rections to rubber gloves in 
dental patients:Br Dent J 172: 445-447,1992. 
• Smith DC: Corrosion of orthodontic bracket bases.AJODO 81,:43-48,1982. 
• Field EA: issues of latex safety in orthodontics:Br DentJ 179:247-253,2001.
• Sanders AJ, Dodge NN: Manging patients who have seizure disorders: dental 
and medical issues J Am Dent Assoc 126:1641-47, 1995. 
• Jacobson P. Epilepsy and the Dental Management of the Epileptic Patient. The 
Journal of Contemporary Dental Practice, Volume 9, No. 1, January 1, 2008 
• Kumar v, mogra s, Shetty v. hepatitis b, the facts and figures of concern to 
orthodontist in india. The Journal of Contemporary Dental Practice, Volume 9, 
No. 1, January 1, 2008 
• Maheshwari s, Verma SK, Ansar J, Prabhat KC. Orthodontic care of medically 
compromised patients. Indian Journal of Oral Sciences Vol. 3 Issue 3 Sep- 
Dec 2012 
• Fabue LC, Soriano YJ, Pérez. Dental management of patients with endocrine 
disorders. J Clin Exp Dent. 2010;2(4):e196-203. 
• Jena AK, Duggal R, Mathur VP, Prakash H, orthodontic care for medically 
compromised patients. J ind orthod society 2004; 37: 160-171
THANKYOU!!!

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MANAGEMENT OF MEDICALLY COMPROMISED PATIENTS IN ORTHODONTICS

  • 1. ORTHODONTIC CONSIDERATIONS IN MEDICALLY COMPROMISED PATIENTS BY-DR JASMINE ARNEJA MDS II YEAR
  • 2. CONTENTS • Introduction • Definition • Infective endocarditis • Metabolic disorders • Diabetes • Adrenal insufficiency • Hematological disorders • Bleeding tendencies • Malignancies • Autiommine • Juvenile rheumatoid arthiitis
  • 3. • Resiratory disease • Asthma • Allergies • Latex • Nickel • Nervous system disorders • Epilepsy • Liver disorders • Immunocompromised states • Others • Effect of drugs on orthodontic treatment • Conclusion • reference
  • 5. INFECTIVE ENDOCARDITIS • 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.
  • 6. HOW IS ORTHODONTICS RELATED TO INFECTIVE ENDOCARDITIS? • 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 appliances. • 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 orthodontic bands • McLaughlin et al 1996 reported bacteremia in 10% patients while fitting orthodontic bands
  • 8. WHO IS AT RISK?
  • 9. ORTHODONTIC CONSIDERATIONS • Contact the patient’s cardiologist to asses the risk • Start the treatment only when the patient exhibits exemplary oral hygiene habits • 0.2% chlorhexidine 5 min before the orthodontic procedure (khurana and martin 1999) • Avoid bands. Use bonded attachments when possible • Regular supportive therapy from a hygienist
  • 10. 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
  • 13. DIABETES • 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).
  • 14. 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.
  • 15. DIABETIC PATIENT AND DENTAL TREATMENT • Identify diabetic patients – • Xerostomia • Candidiasis • Glossopyrosis • Recurrent oral infections • Ketone breath • Poor periodontal health • Multiple carious teeth
  • 16. Factors responsible for these oral manifestations- • Abnormal collagen metabolism • Altered protein metabolism due to hyperglycemia • Impaired neutrophil chemotaxis and macrophage function
  • 17. 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 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 usual.
  • 18. 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
  • 19. 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 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.
  • 20. ORTHODONTIC CONSIDERATIONS • 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.
  • 22. ASTHMA • 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.
  • 23. ORTHODONTIC CONSIDERATIONS Before treatment: • 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 controlled. • 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.
  • 24. 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.
  • 25. ACUTE ASTHAMATIC ATTACK In case of acute attack, following steps should be taken. • •Discontinue the procedure and allow the patient to assume a comfortable position. • •Maintain a patent airway and administer bronchodilator via inhaler/nebulizer. • •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
  • 27. LATEX ALLERGIES Type I • 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). Type IV • 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.
  • 28. • 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.
  • 29. ORTHODONTIC MANAGEMENT • 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 aerosolized allergens • 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
  • 31. NICKEL ALLERGY • 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.
  • 32. 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 appliances Intraoral reactions included redness, swelling, itching and soreness of the lips and oral mucosa, and inflammation of the gingival tissues
  • 33. ORTHODONTIC MANAGEMENT • 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
  • 35. EPILEPSY • 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.
  • 36. 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
  • 37. SIDE EFFECTS OF ANTIEPILEPTIC DRUGS • gingival hyperplasia ( 50% of patients treated with phenytoin, sodium valproate and ethosuximide). • recurrent apthous-like ulcerations, • gingival bleeding, • hypercementosis, • root shortening, • anomalous tooth development, • delayed eruption and • cervical lymphadenopathy.
  • 38. ORTHODONTIC CONSIDERATIONS • 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 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 patient’s eyes.
  • 39. • 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 overgrowth
  • 40. EPILEPTIC EMERGENCIES • Remain calm • Remove all dental instruments and removable appliances from the patient’s vicinity • 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 emergency help.
  • 42. JUVENILE RHEUMATOID ARTHRITIS • 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 to the destruction of articular cartilage and ankylosis of the joints. • Temporomandibular joint (TMJ) can be damaged up to complete bony ankylosis.
  • 43. 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
  • 46. ORTHODONTIC CONSIDERATIONS • 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 brushing. • Regular professional scaling • Recommend use of an electric toothbrush • Sugar-free medicines should be preferred to minimize caries.
  • 48. BLEEDING DISORDERS The main inherited coagulation disorders include hemophilias A and B and von Willebrand's disease. • 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
  • 49. 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 needed. • 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 haemophilia. • Wherever possible a nonsurgical approach should be adopted.
  • 50. ORTHODONTIC CONSIDERATION • Excellent oral hygiene is must for preventing gingival bleeding before it occurs. Every effort should be made to avoid any chronic irritation from orthodontic appliance. • 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 prescribed • Bleeding can be managed by replacement of missing clotting factors, so extractions and orthognathic surgery is not contraindicated if managed carefully
  • 52. • More than 40% paediatric malignancies are hematological either leukemia or lymphoma. • 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.
  • 53. ORTHODONTIC CONSIDERATIONS • 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 recommended. • 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
  • 55. RENAL FAILURE • 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 orthodontic treatment.
  • 56. ORTHODONTIC CONSIDERATIONS • 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 hyperplastic gingiva
  • 58. LIVER DISEASES • 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.
  • 59. HEPATITIS B • 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.
  • 60. ORTHODONTIC CONSIDERATIONS •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. •
  • 61. •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.
  • 62. 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%
  • 63. ORTHODONTIC CONSIDERATIONS • 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 of dental caries. • Therefore, it is critical that the oral hygiene and health of children and adolescents receiving ARV medications be attended to daily.
  • 64. • 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
  • 65. • 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.
  • 67. PREGNANCY • 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.
  • 68. 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 heal. • 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 tooth morphology • 40% ED patients show TMJ dislocation during treatment
  • 69. ORTHODONTIC CONSIDERATIONS • 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.
  • 70. INFLUENCE OF DRUGS ON 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
  • 71. • 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 interferes with 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.
  • 72. CONCLUSION • 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.
  • 73. REFERENCES • Burden D, Mullally B, Sandler J. Orthodontic treatment of patients with medical disorders. Eur J Orthod. 2001 Aug;23(4):363-72. • Parnell AG. The medically compromised patient. Int Dent J. 1986 Jun;36(2):77- 82. • Singaraju G, Vannala v. Management Of The Medically Compromised Cases In Orthodontic Practice . Asian Journal of Medical Sciences 1 (2010) 68-74 • Smrat ER, Macloid RL, Laerence CM: Allergic rections to rubber gloves in dental patients:Br Dent J 172: 445-447,1992. • Smith DC: Corrosion of orthodontic bracket bases.AJODO 81,:43-48,1982. • Field EA: issues of latex safety in orthodontics:Br DentJ 179:247-253,2001.
  • 74. • Sanders AJ, Dodge NN: Manging patients who have seizure disorders: dental and medical issues J Am Dent Assoc 126:1641-47, 1995. • Jacobson P. Epilepsy and the Dental Management of the Epileptic Patient. The Journal of Contemporary Dental Practice, Volume 9, No. 1, January 1, 2008 • Kumar v, mogra s, Shetty v. hepatitis b, the facts and figures of concern to orthodontist in india. The Journal of Contemporary Dental Practice, Volume 9, No. 1, January 1, 2008 • Maheshwari s, Verma SK, Ansar J, Prabhat KC. Orthodontic care of medically compromised patients. Indian Journal of Oral Sciences Vol. 3 Issue 3 Sep- Dec 2012 • Fabue LC, Soriano YJ, Pérez. Dental management of patients with endocrine disorders. J Clin Exp Dent. 2010;2(4):e196-203. • Jena AK, Duggal R, Mathur VP, Prakash H, orthodontic care for medically compromised patients. J ind orthod society 2004; 37: 160-171