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medically compromised patients


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medically compromised patients

  1. 1. Supervisors : Prepared by : Dr Ahmad Tarawneh Dr Luma Najada Dr Raghda Shammout Dr Anwar Rahamneh Dr Hanan Habarneh
  2. 2.  Contents: A. Introduction B. Medical disorders 1. Cardiovascular disease 2. Haematological disease 3. Respiratory disease 4. Neurological disease 5. Prosthetic joints 6. Pregnancy 7. Allergies 8. Endocrine disease 9. Cerebral palsy and learning difficulties 10. Musculo-skeletal disorders 11. Kidney disorders 12. Blood borne viruses 13. Side effects of medications 14. Eating disorders 15. down syndrome & Autism 16. MRI and CT scan
  3. 3.  The goal of a treatment plan is to achieve optimal oral health, esthetics, and function for the patient. In treatment planning for an orthodontic patient, there are two primary questions to be addressed: What is the patient’s main concern? And, perhaps even more important, are there any medical contraindications or significant considerations to be mindful of in treatment planning?  A thorough review of the medical history is the most significant procedure to determine whether there are contraindications or important modifications to the treatment of the particular case.
  4. 4.  The medical history should be comprehensive, kept safely with the patient’s record, and updated regularly : 1. At the first visit of a patient to the clinic. 2. At the start of any new course of orthodontic treatment. 3. Before referral to another practitioner for treatment.  Full medical details should be taken from the patient or parents , and checked by the patient’s doctor For those with serious medical problems.
  5. 5. Cardiovascular disease 1. Infective endocarditis. 2. Hypertension.
  6. 6. 1. Infective endocarditis  Its incidence does not appear to be higher during orthodontic treatment, only 4 cases have been reported in relation to orthodontics.  bacteraemia can be increased by plaque accumulation which in turn increased with orthodontic appliances.  Adjustments of appliances never been associated with bacteraemia nor removal of orthodontic mini-implants.  Procedures that can cause bacteraemia: 1. Impression 2. Separator placements 3. Fitting or removing bands 4. Surgical exposure of teeth.
  7. 7.  Management : 1. Informed consent – patient needs to know of any increased risk and about the uselessness of AB. 2. High standard OH with daily antimicrobial M/W- to aid plaque control, particularly for 2 days up to fitting or removal or major adjustment of fixed appliances. 3. Bonded appliances preferred to banded . 4. Un-erupted teeth - avoid bonding w closed eruption. 5. Antibiotic prophylaxis  In high risk cases all procedures causing bacteraemia should be covered . ( High risk cases : prosthetic cardiac valves, previous bacterial endocarditis, complex cyanotic congenital heart disease, surgically constructed systemic pulmonary shunts).
  8. 8.  Precautions :  As an initial step the orthodontist should communicate with the patient's physician to confirm the risk of IE.  treatment should never be commenced until the patient has excellent oral hygiene and dental health.  A non-extraction approach is preferred, if xtn planned inform pt’s cardiologist.  prevent gingival bleeding before it occurs - best achieved by maintaining excellent oral hygiene, and avoidance of any form of gingival or mucosal irritation.
  9. 9.  Arch wire should be secured with elastomeric modules rather than wire ligatures and special care is required to avoid mucosal cuts when placing and removing the wire.  NICE guidelines 2008 no Antibiotic nor chlorohexidine MW are given except very high risk patients.  Post-op dose of antibiotic is no longer recommended.
  10. 10. No penicillin Allergy : Amoxycillin orally 1 hr pre-op penicillin Allergy : clindamycin orally 1 hr pre-op 0-5 years 750mg 100mg 5-10 years 1.5g 300mg 10+ years 3g 600mg Antibiotic prophylaxis regime
  11. 11. 2. Hypertension  No contraindications for well-controlled hypertensive patients- defer elective tx if uncontrolled.  Get physician appraisal.  Always detect the gingival health as hypertensive drugs have been associated with gingival overgrowth. Surgical resection of the enlarged tissues is effective in preventing recurrence.  Avoid any form of gingival irritation.  Minimizing stress is important.  appointments should be less than one hour to minimize stress.
  12. 12.  Maintaining periodontal health and good oral hygiene, educating the patient on this, and recommending specific oral hygiene aids.  Calcium channel blockers can cause gingival hyperplasia in addition to the irritation caused by the fixed appliance. Depending on the condition refer the patient back to his cardiologist to prescribe an alternative therapy.
  13. 13. Haematological disease  1. bleeding disorders  2. sickle cell anemia  3. haematological malignancies  4. Thalassemia
  14. 14. 1. Bleeding disorders (hemophilia)  No contraindicatios-consult haematologist before any invasive treatment.  Fixed appliances are preferable to removable appliances- gingival irritation.  Self-ligating brackets are preferable to conventional brackets, If conventional brackets are used, arch wires should be secured with elastomeric modules.  If xtn cannot be avoided, primary closure with suturing and supplementation of factor 8 may be required  A Vacuum formed aligners may be the appliances of choice for selected malocclusions.
  15. 15.  Avoid drugs that increase bleeding tendency (aspirin) or cause gastric bleeding (NSAID).  Be careful in prescribing analgesia and other drugs since Warfarin interacts with other drugs (aspirin, NSAID, metronidazole, erythromycin, cephalosporins and tetracyclines).  The duration of treatment should be kept to a minimum to reduce the potential for complication.
  16. 16. 2.Sickle cell anemia  Maintain Good oral hygiene  Avoid emotional stress .  Avoid EOA - compromise the airway  An Extraction is contraindicated-if necessary they are best carried out in a hospital.  General anaesthetics for elective procedures are contraindicated so orthognathic surgery is not recommended ( deoxygenation induce red cell to deform to a sickle shape).  ↓ orthodontic forces and ↑ resting period between activation with Long treatment duration – to restore the regional microcirculation.  Be aware of possible pulpal necrosis involving healthy teeth, the changes in bone turnover, mandibular vaso- occlusive crises, and the greater susceptibility to infections.
  17. 17. 3. Haematological malignancies  50% of childhood malignancies are leukaemias or lymphoma.  Orofacial complications : lymphadenopathy, spontaneous gingival bleeding caused by thrombocytopenia , ulceration, gingival swelling, and infection..etc  After diagnosis : treatment should be postponed if the patient requires chemotherapy.  After treatment : treatment should be postponed until at least 2 years after BMT - relapse of the malignancy has diminished and the patient is no longer on immunosuppressive therapy, the growth rate and the need for supplemental growth hormone have been assessed.  If malignancy is diagnosed during treatment remove appliances and use retainers.
  18. 18.  TBI (Total body irradiation) can suppress growth, so the prognosis for growth modification in skeletal Class II malocclusions is guarded  Treatment mechanics should be aimed at minimising the risk of root resorption, keeping the forces low and accepting a compromised treatment result.  Patients with short blunt roots : monitor the crown/root length after 6 months of fixed appliance treatment. If there is apical root resorption, archwire should be left passive for 3 months.  Caries risk may be ↑ due to salivary dysfunction- excellent OH,topical fluoride application and artificial saliva may be recommended.
  19. 19.  Side effect of anti-cancer treatment is a reduced resistance to infections and atrophy of the oral mucosa. Even minor irritation from orthodontic appliances can lead to severe ulceration-Vacuum formed aligners may be the appliances of choice.  Do not treat lower jaw; as its at risk of ORN because of its limited blood supply. Indian journal of oral sciences 2013  Atraumatic extraction techniques should be applied to reduce the risk of ORN.
  20. 20. 4. Thalassemia  Antibiotic prophylaxis must be given during invasive procedures like extraction.  Functional & EO appliances : skeletal forces must be less than what is used with normal patients - thin cortical plates.  Radiographs at 3 months intervals - thin cortical plates complicate orthodontic treatment.  Extraction should be carried out at the time of admission for blood transfusion .  Patients are at an increased risk of viral hepatitis and AIDS due to repeated blood transfusion and therefore screening test for the same should be carried out at regular intervals.
  21. 21. Respiratory disease  1. asthma  2. cystic fibrosis  3.Tuberculosis
  22. 22. 1.Asthma  Consult the patient’s physician .  First goal is to prevent acute asthmatic attack - avoid any triggers factors and ensure that patient is carrying inhaler.  Treat early in the day and minimise stress to reduce risk of attack.  patients is at a high risk for developing excessive root resorption, low forces is needed.  Chronic use of corticosteriod inhalers develop candidial infection esp with pt wearing removable appliance - rinse with water after inhaler is requested.  Patient may be allergic to NSAIDS  Avoid rubber dams.  Care should be used in the positioning of suction tips as they may elicit a cough reflex.
  23. 23.  How to manage an acute asthmatic attack in the dental office ?  1. Discontinue the dental procedure and allow the patient to sit up or lie down in a comfortable position  2. Keep the airway open and administer Beta2-agonists with inhaler  3. Administer oxygen via face mask nasal hood  4. If no improvement takes place and the patient is worsening, administer epinephrine subcutaneously (1:1000 solution, 0.01 mg/kg of body weight to a maximum dose)
  24. 24. 2.Cystic fibrosis  Oral effects : hypoplastic enamel, reduced salivary flow and delayed eruption.  Consult the physician  Good OH because of dryness  Avoid GA . Postpone extractions untill patient is old enough to have local anasthesia .  Short compromised treatment
  25. 25. 3.Tuberculosis  Elective dental treatment including should be deferred until a physician confirms that a patient does not have infectious TB.  The challenge to orthodontics is to be prepared for all infectious diseases that may affect the practice.
  26. 26. Neurological disorders  1. epilepsy  2. multiple sclerosis.  3. Hydrocephalus and Cerebrospinal shunts
  27. 27. 1. Epilepsy  Anti-epileptic drugs should be taken regularly.  Sedation - in stress induced procedure.  Use mouth prop at the beginning of procedure  if poorly controlled avoid removable App,bands, EO appliances.  If an individual having a class II Division I incisor relationship experiences an aura before a seizure, he should carry a soft mouth guard with palatal coverage and extending into the buccal sulci to use at such times.  Small low profile brackets .  Avoid Space closing mechanics : nickel titanium closing springs, elastomeric power chain or active elastics because they affect the hyperplastic gingival tissue.
  28. 28.  Essix based retainers should be relieved around the gingival margins.  Bonded retainers are avoided in patients at risk of DIGO  past dental or facial trauma should be considered when planning treatment and reviewed as part of patient informed consent.  Anti-epileptic drugs side effects include gingival hyperplasia, ulcerations, gingival bleeding, hypercementosis, root shortening, anomalous tooth development, delayed eruption, and xerostomia  supplemental topical fluoride
  29. 29.  Appointments should be scheduled during a time of day when seizures are less likely to occur.  Investigative procedure such as MRI should be taken prior to treatment as the metal components may distort the image,an acceptable MRI may be obtained if arch wires and other removable components are removed before the scan  Removable appliances should be designed for maximum retention and made of high impact acrylic.  Regular preventative dental care to avoid dental disease.
  30. 30.  How to manage an epileptic attack in the dental office ?  1. Clear all instruments away from the patient.  2. Place the dental chair in a supported, supine position as near to the floor as possible.  3. Place the patient on his or her side (to decrease the chance of aspiration of secretions.  4. Do not restrain the patient.  5. Do not put your fingers in his mouth.  6. Time the seizure (the duration of the event may seem longer than it actually is).  7. Call 911 if the seizure lasts longer than 3 minutes or the patient becomes cyanotic .
  31. 31. 9. Administer oxygen at a rate of 6–8 L/minute. 10. If the seizure lasts longer than 1 minute or for repeated seizures, administer a 10-mg dose of diazepam intramuscularly (IM) or intravenously (IV), or 2 mg of ativan, IV or IM, or 5 mg of mid-azolam, IM or IV. 11. Be aware of the possibility of compromised airway or uncontrollable seizure
  32. 32.  Once the seizure is over :  1. Do not undertake further dental treatment .  2. Try to talk to the patient to evaluate the level of consciousness.  3. Do not attempt to restrain the patient.  4. Do not allow the patient to leave the office if his level of awareness is not fully restored.  5. Contact the patient’s family, if he is alone.  6. Do a brief oral examination for sustained injuries.  7. Depending on consciousness, discharge the patient home with a responsible person, to his family physician or to an emergency room for further assessment.
  33. 33. 2. multiple sclerosis  May not tolerate long appointments.  May not tolerate use of intermaxillary traction.  Need multidisciplinary approach  Custom made toothbrush handles - improve grip  electric toothbrushes - compensate for the loss of manual dexterity and coordination.  Patients with spasms - allowed to get out of the dental chair and move around to relieve them.  Individuals with dysphagia should be treated in a semi- reclined position  severe MS - best treated to a compromised result.  Removable appliances may not be tolerated well.
  34. 34.  ABP may be needed – consult specialist 3. Hydrocephalus and Cerebrospinal shunts
  35. 35. Prosthetic joints  No AB prophylaxis needed
  36. 36. Pregnancy  Gingivitis results from ↑ level of progesterone and estrogen- exaggerated gingival inflammatory reaction to local irritants.  Maintain a healthy oral environment .  Extensive elective procedures, such as surgical exposure of impacted tooth should be postponed until after delivery.  Avoid X-rays or drug therapy, particularly in the first trimester.  Prescribe medications based on drug safety categories.  Avoid supine position in late pregnancy.
  37. 37.  Patients have a high awareness of and sensitivity to taste, smell and environmental temperature. Unpleasant tastes and odours can cause severe nausea , gagging and vomiting.  Patients should be well hydrated, and the duration of chair treatment time should be as short as possible.
  38. 38. allergies  1. latex allergy  2. nickle allergy  3. bis-gma allergy
  39. 39. 1. latex allergy Who at risk?  Patient with allergic rhinitis,Asthmatic ,Eczema, hypersensitive to certain food,Atopic patients, Patients with spina bifida,Healthcare professional, Latex industry worker... Etc  Management : 1. Definitive diagnosis:  Patch testing ,Pin prick testing, Blood test.  If latex allergy suspected refer to dermatologist 2. Staff training : should be aware of emergency protocols for dealing with anaphylactic reactions .
  40. 40. 3. Appointment :  Treat as first patient of the day to minimise airborne particle risk. 4. Appliance design and handling  Latex free gloves.  self-ligating brackets to avoid elastomeric ties.  Space closure with nickel– titanium coils.  Inter-maxillary elastics : latex-free elastics ( although they are subject to greater force degradation).  Medical history need up to date.  Elastomeric separators can be replaced with self-locking separating springs.
  41. 41.  Types of reaction to Latex:  1. Type I hypersensitivity reaction  5-60 minutes after contact .  Severe systematic reactions have been reported following cutaneous/respiratory exposure  Flare and wheal to anaphylactic shock.  May induce delayed hypersensitivity reaction ( type 4)  2. Type IV hypersensitivity reaction (Allergic contact dermatitis)  Due to chemicals in gloves  Eczema rash and skin maybe swollen, vesicular and weeping  Signs & Symptoms: Rapid weak, Facial flushing, itching, cold extremities, bronchospasm, Loss of consciousness, Facial edema, Deep fall in BP .
  42. 42. 2. Nickel allergy  ↑ in asthmatic patients  More serious if contact the skin than mucosa, 5 - 12 times the concentration of nickel required to provoke mucosal lesions compared with skin lesions  Nickel is found in arch wires, bands, brackets and headgear.  Signs and symptoms of nickel allergy:  1. For the gingivae:  Gingivitis in the absence of plaque  Gingival hyperplasia
  43. 43.  2. For the tongue:  Burning sensation  Metallic taste  Numbness sensation  Soreness of the side of the tongue  3. For the lip:  Labial swelling  Angular cheilitis  4. EO signs  dermatitis in sites of prolonged skin contact with nickel- containing objects (headgear studs.)
  44. 44.  Management :  1. Definitive diagnosis:  History  In case of doubt, a trial appliance can be placed which may include two to four brackets with a Ni-Ti archwire and assess a reaction.  blood test.  2. Appliance design and handling  A. Nickel free brackets  SS because it releases less nickel than NiTi  Ceramic brackets  Polycarbonate brackets  Titanium brackets  Gold brackets
  45. 45.  B. Nickel free archwires  No evidence of archwires causing reactions.  Titanium Molybdenum alloy (TMA) archwires  Fibre-reinforced composite archwires  Pure Titanium archwires  Gold plated archwires  C. Extra oral appliances  exposed metalwork should be covered with tape or plasters or headgear use discontinued.  Plastic coated headgear studs .
  46. 46. 3. BIS-GMA allergy  Allergic contact dermatitis to dental materials uncommon for patients but may become an issue for dental team.  Avoid placing polymer on hands to reduce risk.  Dental materials in their pre-polymerised state are potential sensitisers.
  47. 47. Endocrine conditions  1. Diabetes mellitus.  2. Thyroid disorders.
  48. 48. 1.Diabetes mellitus  Avoided in poorly controlled DM  Morning appointments.  If longer sessions are scheduled then patient is advised to take meal and medication  Periodontal health is to be evaluated regularly.  Strict oral hygiene measures .  Orthodontic forces are kept to minimum because there is weakening of periodontal ligament and osseous regeneration.  The orthodontic team should be trained to deal with diabetic emergencies  Oral complications include : xerostomia, burning mouth, candidal infection, altered taste, progressive periodontal disease, dental caries, acetone breath, parotid enlargement, delayed wound healing.
  49. 49.  vitality of the teeth should be checked regularly - Diabetic related microangiopathy affect the peripheral vascular supply, resulting in unexplained toothache, tenderness to percussion and loss of vitality.  There is no treatment preference with regard to fixed or removable appliances.
  50. 50.  Diabetic emergencies are two complications :  Hypoglycemia  Symptoms : rapidly occur ,appear intoxicated, signs of anger, confusion ,hungry, ↑ BP.  If not treated convulsion, coma, or death.  Hyperglycemia  Symptoms : occur slowly ,flushed and warm, thirsty ,fruity odour breath,vomiting, ↓BP.  Treat both as hypoglycemia :  Conscious : 50 g of glucose as a drink, tablet or gel.  Unconscious : 20 ml of 50% Dextrose IV or 1 mg of glucagon IM.  When the patient is cooperative oral glucose should be given to prevent recurrent hypoglycaemia. If recovery is delayed, the emergency services should be called.
  51. 51. 2. Thyroid disorders  hypothyroidism  patients are more susceptibile to cardiovascular disease. Check cardiovascular statuses first.  oral findings: macroglossia, delayed eruption, poor periodontal health ,delayed wound healing .  hyperthyroidism  Oral findings : Early eruption and premature shedding of deciduous dentition, followed by accelerated emergence of permanent dentition.
  52. 52.  Require minimal alterations in patient with managed thyroid disease.  In hyperthyrodiosm enlarged tongue may pose problem during treatment.  The bone turn over can influence orthodontic treatment : High bone turnover (hyperthyrodism) increase amount of teeth movement Low bone turnover (hypothyrodism) increase the risk of root resorption.
  53. 53. Cerebral palsy and learning difficulties  Good motivation and oral hygiene  Ensure parent is supportive of treatment.  Keep treatment simple  Use URA if possible  Sedation - to ease treatment.  Oral hygiene , drooling and manual dexterity maybe a problem  Clinician approach to behaviour management must be flexible and longer appointments may be required
  54. 54. Musculo-skeletal disorders  1. juvenile idiopathic arthritis  2. osteoporosis  3. rickets
  55. 55. 1. Juvenile Idiopathic Arthritis  Limiting mouth opening -difficulty in brushing.  Oral hygiene aids - modified toothbrush handles & electrical toothbrushes  Bite splint – to unload the joint during acute periods of inflammation.  A distracted splint to modify mandibular growth in the same way as conventional functional appliances.  The use of functional appliances in patients is a debatable area. It has been argued that functional appliances and class II elastics put increased stress on the TMJs and should be avoided; however, it has also been suggested that functional appliances protect the joints by relieving the affected TMJ.
  56. 56.  Drugs used : steriods which may affect growth, and NSAIDS which may inhibit tooth movement.  Destruction of condyles is common.  No clear guidlines on treatment.  Patients with severe disease have characteristic facial morphology : skeletal Class II and open bite malocclusions.  Surgery can be considered if the problem cannot be treated orthodontically; however, it has been suggested that mandibular surgery should be avoided and instead a patient with severe mandibular deficiency should have maxillary surgery and a genioplasty
  57. 57. 2. osteoprosis  Drugs used : bisphosphonate, estrogen .  Estrogen has no effect on orthodontic tx, not widely used anymore.  Tx must include the consideration of problems such as bone loss, retention instability and Tmj dysfunction.  BP affect treatment by delaying tooth eruption, inhibit tooth movement, and impaired bone healing by causing bp-induce ORN of jaws.  Assess the risk of osteoradionecrosis - route of administration, duration of treatment, dose and frequency of use.  If possible, treatment should be carried out prior to BP treatment.
  58. 58.  In patients at high risk of ONJ, it may be better to accept the malocclusion and consider the benefits of cosmetic dentistry  Avoid Extraction- BP indeuce ORN.  patients who take oral BPs are no more at risk of implant or temporary anchorage device failure than other patients  Orthodontic tx is possible after 3 months with no BP therapy.
  59. 59. 3. Rickets  The child has retarded growth.  Impaired growth may influence our treatment plan in case of functional appliances.  Orthodontic forces are kept to minimum.
  60. 60. Kidney disorders  The most common is CRF .  treatment is not contraindicated in well controlled patients.  postpone if renal failure is advanced and dialysis is imminent.  If necessary treatment can be carried out it should be prior to transplantation to avoid the risks associated with immunosuppressant drugs.  Appointments on non-dialysis days and the day after dialysis is the optimum time for treatment for surgical procedures .  Surgical procedures are best carried out under local anaesthetic.  The anaemia and the potential electrolyte disturbances that can predispose the patient to cardiac arrhythmias can complicate general anaesthesia
  61. 61.  OH  Reduce treatment  Avoid ulceration and sharp edges  Light force  Avoid extractions  The value of prophylactic antibiotics in renal transplant patients on prevention of post-operative complications is questionable or unproven, consult patient’s physician
  62. 62. Transplant patient and immunosuppression  Drugs include cyclosporin induce gingival hyperplasia.  Treat prior to transplant if possible, but defer if transplant imminent.  Orthodontic treatment should be simple.
  63. 63. Blood borne viruses (Hepatitis B, C, D and G, HIV)  All patients are treated as infected and universal cross- infection control precautions are to be followed  All members of the team must be immunized against HBV ,Follow up and booster dose are done regularly  wear heavy utility gloves and personal protective equipment  Increase tendency to infection and ulceration  Increase tendency to bone resorption because of the hepatic malfunctioning.
  64. 64.  Instruments used on these patients are carried in the instrument processing area cautiously to prevent cross contamination.  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.  Patients undergoing liver transplantation will be receiving immunosuppressive drugs that can cause gingival hyperplasia.  Haemostasis will be affected and this should be accounted for when planning treatment.
  65. 65.  HBVcan survive for 7 days, Impressions can be one of the links in transmitting the virus- must be disinfected by dipping them in glutaldehyde or by spraying sodium hypochlorite and leaving it for 10 min.  If extraction is required, special attention should be paid as the risk of bleeding increases; an infusion of fresh frozen plasma may be indicated.
  66. 66. Side effects of medications  1. prostaglandin inhibitors.  2. oral contraceptive.  3. bisphosphonate
  67. 67. 1.Prostaglandin inhibitors  Drugs affect prostaglandin activity :  1. corticosteriods and NSAIDS.  2. other agents have agonist and antagonsit effect on prostaglandin.  Prostaglandins are formed from arachidonic acid which in turn derived from phospholipid  Corticosteriods reduce prostaglandin synthesis by inhibiting the formation of AA, NSAIDS inhibit the conversion of AA to prostaglandins.
  68. 68.  Low doses and short duration of analgesic therapy in orthodontic patient dosent interfere with tooth movement, but it can become a problem in adults or children being treated for arthritis.  Several other drugs can affect prostaglandin levels include tricyclic antidepressents, antiarrhythmic agents, antimalarial drugs, anticonvulsant drugs and tetracycline.
  69. 69. 2. Oral contraceptives  Antibiotic therapy can reduce effectiveness of the pill  Always warn
  70. 70. Eating disorders  The most common are anorexia nervosa (AN) and bulimia nervosa (BN).  referral should be done to the patient's physician.  Patients should be counseled not to brush their teeth immediately after vomiting.  They should be given advice on how to increase the intra- oral pH by chewing gum, or rinsing the mouth with water or milk.
  71. 71. Down syndrome  Children with heart defects should be given AB prophylaxis –IE .  OHI- every visit.  Ensure that patient is vaccinated for hepatitis before starting dental treatment – patients are at increased risk of developing the carrier state if they are infected with HBV.  Seizures occur in 5-10% of children with Down syndrome.  Impressions using quick-set materials -reduce the tendency for activation of the more sensitive gag reflex frequently experienced with Down syndrome patients.  High-memory wires - longer activation interval between appointments.  Self-ligating brackets- more patient friendly activation appointment.
  72. 72. Autism  The main challenge is the communication .  The 1st several visits : raising the patient's confidence and determining the maximum level of compliance that is achievable.  At the same time, an estimate of the most suitable way (behavior management, sedation or general anesthesia ) to perform the more difficult procedures, such as impressions or bracket bonding may be made.  Jackson was the first to suggest using GA for the placement of orthodontic bands.  Patient should be treated in a quiet, shielded single operatory arrangement, with reduced decoration and dimmed lights.  Procedures such as tell-show-do, voice control, and positive reinforcement are effective with children.
  73. 73. MRI and CT scan  CT images not affected by products used in orthodontic treatment.  All removable appliances or easy-to-remove components, e.g. Spring or archwire, should be removed before MRI.  All fixed components, e.g. brackets, bands or tubes, can remain in the patient’s mouth, as long as they are firmly bonded and carefully ligated  Ceramic brackets with a metal slot and titanium brackets cause no artefacts on MRI images, only have to be removed if the area under investigation is close to the fixed appliances, i.e. in the oral cavity.
  74. 74.  SS brackets and retainers caused extensive artefacts- should always be removed before MRI images of the head and neck area are taken.  If the dento-alveolar region is the study, the plane of the scan should be altered to avoid the site of metal devices
  75. 75. references  Postgraduate Notes in Orthodontics (7th Edition) for DDS and MOrth programmes from the University of Bristol.Importance of orthodontic considerations in medically compromised patients- part I,Reddy R*, Satish M**, Pasam N****Department of Orthodontics, Rungta Colleges of Dental Sciences and Research, Bhilai**Department of Oral and Maxillofacial Surgery, Rungta Colleges of Dental Sciences and Research, Bhilai***Department of Prosthodontics, Rungta Colleges of Dental Sciences and Research, Bhilai.  Clinical Management of Medical Disorders in Orthodontics Anila Charles1,*, Senkutvan RS1, Sanjay Jacob1, Krishnan C.S2, Sivaram Subbiah3 1Department of Orthodontia, Madha Dental College, M.G.R University, Chennai 2Department of Periodontics, Madha Dental College, M.G.R University, Chennai 3Department of Orthodontics Penang International Dental College  The Importance of a Complete Medical History in Orthodontic Treatment Planning by Joycelyn A. Dillon, RDH, MA  Orthodontic Management of Medically Compromised Patients ,Mohammed Almuzian , glasgow university.  Orthodontic treatment of patients with medical disorders,Burden D1, Mullally B, Sandler J  Contemporary Orthodontics, 5th Edition, by William R. Proffit, DDS, PhD, Henry W. Fields, DDS, MS, MSD, and David M. Sarver, DMD, MS.  Postgraduate Notes in Orthodontics (7th Edition) for DDS and MOrth programmes from the University of Bristol.  Orthodontic care of medically compromise patients, sandhya maheshwari  Medical disorders and orthodontics  Anjli Patel  Chesterfield Royal Hospital NHS Foundation Trust, Charles Clifford Dental Hospital, Sheffield, UK  Donald J Burden  Orthodontic Division, The Queen’s University of Belfast, UK  Jonathan Sandler  Chesterfield Royal Hospital NHS Foundation Trust, UK  Orthodontic care of medically compromised patients Sandhya Maheshwari, Sanjeev Kumar Verma, Juhi Ansar, KC Prabhat Department of Orthodontics and Dental Anatomy, Aligarh Muslim University, Aligarh, India  Orthodontic products and appliances during magnetic  resonance imaging and  computer tomography by Dr Christoph Schippers  : Influence of common fixed retainers on the diagnostic quality of cranial magnetic resonance images  Magnetic resonance imaging artefacts and fixed orthodontic attachments  Aurélien Beau  Denis Bossard  Sarah Gebeile-Chauty  Eur J Orthod (2015) 37 (1): 105-110.  DOI:   Published:  04 July 2014