S y s t e m i c F a c t o r s A ff e c t i n g

O r t h o d o n t i c Tre a t m e n t
O u t c o m e s a n d P ro g n o s i s – Pa r t 1
Sumit Gupta, BDS, MDSa,*, Anil Ardeshna, DMD, MDSb,
Paul Emile Rossouw, BSc, BCHD(Dent), BCHD-Hons(Child Dent), MCHD (Ortho),
c
PhD, Cert (Ortho), PhD (Dental Science), FRCD(C) ,
d
Manish Valiathan, BDS, MDS, DDS, MSD

KEYWORDS
 Renal diseases  Liver diseases  Orthodontic treatment  Periodontal issues
 Tooth eruption  Osteoporosis

KEY POINTS
 Renal diseases impact dental health, causing delayed tooth eruption and gingival over-
growth, necessitating orthodontic caution and collaboration with physicians.
 Liver diseases correlate with periodontal issues; hepatitis transmission risk requires strin-
gent infection control measures during orthodontic procedures.
 Osteoporosis affects orthodontic treatment due to bisphosphonate use, potentially inhibiting
tooth movement, while orofacial muscle dysfunctions like open bite require specialized care.
 Ehlers-Danlos syndrome demands careful orthodontic management due to collagen-
related fragility, rapid tooth movement, and heightened risk of periodontal problems
and orthodontic relapse.
 Autoimmune diseases such as diabetes mellitus and juvenile idiopathic arthritis require
tailored orthodontic approaches considering oral complications and joint involvement,
emphasizing collaboration and cautious treatment planning.

INTRODUCTION

The objective of orthodontic treatment is to set an appropriate treatment plan to attain

the best balance and harmony of facial lines (esthetic), a healthy oral environment,

a
Diplomate, American Board of Orofacial Pain, Private Practice, Rak Dental Care & Implant
Centre, Ras Al Khaimah, United Arab Emirates; b Diplomate American Board of Orthodontics,
Department of Orthodontics, Rutgers School of Dental medicine, 110 Bergen Street, Newark,
NJ 07101, USA; c Division of Orthodontics and Dentofacial Orthopedics, University of Rochester
Eastman Institute of Oral Health, 625 Elmwood Avenue, Box 683, Rochester, NY 14620, USA;
d
Department of Orthodontics, Case Western Reserve University, 9601 Chester Avenue, Cleve-
land, OH 44106, USA
* Corresponding author. 304 NS Tower, Al Qassimi Street, Corniche, PO Box 11939, Ras Al Khai-
mah, UAE.
E-mail address: [email protected]

Dent Clin N Am 68 (2024) 693–706

https://doi.org/10.1016/j.cden.2024.05.004 dental.theclinics.com
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AI training, and similar technologies.
694 Gupta et al

functional dentition, and stable result.1 However, few studies have shown that it is
necessary to adjust or change a treatment plan, especially when associated with a
systemic disorder.2–5
There is also an increased demand for contemporary orthodontic treatment regard-
less of hidden medical disorders. Thus, early diagnosis may lead to adequate man-
agement of an underlying disease that may prove difficult to overcome because of
hidden difficulties during and after orthodontic treatment. Moreover, it is important
to recognize and incorporate orthodontic treatment goals to accommodate systemic
disease problems to warrant attaining the noted treatment goals. The following 2
articles, part 1 and 2, will address some of these problems to equip the clinician
with an understanding and knowledge to manage examples of systemic disease dur-
ing orthodontic treatment.2–5

MALIGNANCIES

Modern methods of cancer treatment have significantly increased survival rates, lead-
ing to an increasing number of children requiring orthodontic treatment after their can-
cer treatment.6 Cancer and its treatments, particularly in childhood, can significantly
impact orthodontic treatment. Radiotherapy can lead to cranio-facial growth interfer-
ence, mandibular retrognathia, and other complications, making orthodontic treat-
ment more challenging. Disturbances in tooth development, root resorption, and
bone density are common in long-term survivors of childhood cancer, but orthodontic
treatment does not produce harmful side effects in these patients.7,8 Similarly, chemo-
therapy and radiotherapy may have lasting effects on systemic health, influencing fac-
tors like bone density, healing capabilities, and susceptibility to infections. Side effects
such as mucosa inflammation and recurrence, necessities an optimized treatment
plan for oncological patients.9 Moreover, the use of ionizing radiation affects the shear
strength and failure mode of ceramic orthodontic brackets bonded with different
composites.10
Survivors of childhood cancer are particularly at risk for late dental effects, empha-
sizing the long-term implications of cancer treatments on dental health.11 Further-
more, the use of bisphosphonates in cancer treatment has been increasingly
recognized for its significant impact on dental treatments.12 Malignancies, especially
those involving the head and neck region, may necessitate alterations in the standard
diagnostic imaging protocols. Radiographic assessments, such as cone-beam
computed tomography scans, play a pivotal role in orthodontic records. However,
alterations in anatomy due to tumor growth or changes induced by cancer treat-
ments may obscure critical structures, influencing the accuracy of cephalometric
analyses and 3-dimensional reconstructions.
The impact of cancer treatments on dental and skeletal structures is a critical
consideration in orthodontic treatment planning.13 Cancer therapies can compromise
the mechanical properties of oral tissues, leading to increased susceptibility to
trauma and delayed healing, as orthodontic forces may need to be modified to
accommodate compromised tissue integrity.14 The study by Cuoghi and colleagues
(2016) delves into the correlation between pain and tissue damage in response to or-
thodontic tooth movement, shedding light on the complexities of tissue response to
mechanical forces.15 Furthermore, the prevalence, intensity, and extent of impacts
on daily performances related to wearing orthodontic appliances among cancer sur-
vivors need to be assessed to understand the full scope of the impact.16 Cancer sur-
vivors undergoing orthodontic treatment experience lower long-term stability of
treatment compared to generally healthy individuals.17 Additionally, cancer survivors,
 Orthodontic Treatment Outcomes and Prognosis 695

especially male patients, report a significantly lower quality of life during orthodontic
treatment.18 The impact of orthodontic treatment on the oral health quality of life is
significantly higher in male cancer survivor patients compared to the control group.9
This emphasizes the importance of considering the positive impact of orthodontic
treatment on the quality of life of cancer survivor patients.

NEUROLOGIC DISORDERS

Neurologic disorders affect a diverse demographic, including children, adolescents,

and adults. The challenges in providing orthodontic treatment to these individuals
stem from the need for individualized care plans, considering the dynamic nature of
neurodevelopmental disorders and their influence on craniofacial growth patterns, pa-
tient compliance, effect on tooth movement, and oral hygiene.
Multiple sclerosis (MS) is a condition characterized by the demyelination, neurode-
generation, and autoimmune response within the central nervous system, typically
impacting younger individuals.19 The prevalence of MS estimated to be 2.2 million
worldwide indicating a 10.4% increase in age-standardized prevalence since 1990.
The prevalence of MS is influenced by a complex interplay of genetic, environmental,
and demographic factors, leading to varying prevalence rates across different regions
globally.20,21 Patients with MS are almost universally infected with Epstein-Barr virus
(EBV), and the risk of developing the disease increases with the level of EBV-specific
antibody titers.22 The symptoms of MS relevant to orthodontic care include fatigue,
weakness, decreased balance, spasticity, gait problems, depression, cognitive is-
sues, bladder, visual and sensory loss, neuropathic pain, and muscle weakness.23
These symptoms may impact a patient’s ability to maintain oral hygiene, attend dental
appointments, or undergo orthodontic procedures. For instance, muscle weakness
and decreased balance may affect a patient’s ability to perform oral care tasks effec-
tively, such as brushing with a regular brush, elastics, removable appliances, or aligner
wear.24 Additionally, bladder and bowel deficits may necessitate accommodations
during dental visits. Furthermore, depression and cognitive issues can impact a pa-
tient’s overall experience and may require special attention and support during dental
and orthodontic care.
Epilepsy is a neurologic disorder characterized by recurrent unprovoked seizures,
often resulting from brain damage due to injury, infection, birth trauma, or cerebrovas-
cular accidents. It can also be associated with genetic syndromes such as Down’s
syndrome or Sturge-Weber syndrome.25 The estimates of prevalence of epilepsy in
the United States (US) from 1% to 5 to 9 per 1000 individuals affecting an estimated
3 million Americans. When considering orthodontic treatment for patients with epi-
lepsy, several factors should be taken into account. Patients should continue their
antiepileptic medication as prescribed and should not be overly fatigued during ap-
pointments. Additionally, the orthodontist should ensure that the patient has eaten
normally before each appointment. It is important for the orthodontic team to be
well-trained in seizure management, and patients should be informed about the risk
of soft tissue and dental injuries during a seizure.26,27 Furthermore, the potential
side effects of antiepileptic medications, such as gingival overgrowth associated
with phenytoin, should be monitored, and removable appliances should be used
with caution due to the risk of dislodgement during a seizure.28 Given the potential
for metal in fixed orthodontic appliances to distort MRI images, the use of ceramic
brackets maybe more appropriate.29
Children with attention-deficit/hyperactivity disorder (ADHD) present unique chal-
lenges in orthodontic treatment, encompassing behavioral, attentional, cooperative,
696 Gupta et al

hygiene, and dental trauma aspects.30 These challenges are further compounded by
the potential adverse effects of orthodontic interventions, such as root resorption,
pain, and periodontal disease. Interventions aimed at enhancing adherence, including
the use of rewards, provision of written information, and plaque demonstration, have
been identified as effective strategies. Moreover, patient anxiety and paternal attitudes
have been recognized as influential factors affecting compliance during treatment. Chil-
dren with ADHD are prone to distraction, have limited sustained attention span, and
may exhibit motor overactivity, emphasizing the need for specialized approaches.
Additionally, children with ADHD have been found to experience dental injuries more
frequently than previously described. Furthermore, the use of methylphenidate in the
treatment of ADHD has been associated with a high risk of dental trauma, necessitating
careful consideration in orthodontic treatment planning.31 Moreover, children with
ADHD have exhibited a higher prevalence of caries and periodontal problems
compared to their peers without ADHD, underscoring the importance of addressing
oral health concerns in this population.32 The impact of ADHD on sleep-disordered
breathing and malocclusion has also been recognized, highlighting the need for
comprehensive assessment and management of orthodontic concerns in children
with ADHD.33
Cerebral palsy (CP) is a non-progressive neurologic disorder that affects movement
and posture, resulting from injury to the developing brain. The most common form of
CP is spastic, accounting for nearly 80% of all cases. Individuals with CP are more
susceptible to malocclusions, particularly class II malocclusion, increased open
bite, and overjet.34,35 Additionally, they are prone to dental caries, oral hygiene chal-
lenges, and dental erosion, often associated with gastroesophageal reflux.36 Further-
more, delayed or advanced dental maturity may be expected in patients with CP
compared with healthy individuals. The use of botulinum toxin for spasticity, a preva-
lent symptom in children with CP, has been extensively evaluated. Moreover, children
with CP often require general anesthesia for dental management due to impaired re-
flexes, involuntary movements, muscle spasms, and cognitive impairment.
Functional and fixed orthodontic treatment, including rapid maxillary expansion and
vertical control, can lead to improvements in occlusion, facial esthetics, speech, and
oral function.37

RESPIRATORY DISEASES

Respiratory diseases encompass a broad spectrum of disorders affecting the respira-

tory system, including the lungs, airways, and other breathing structures.38 Patients
with respiratory diseases may face challenges during orthodontic treatment due to
several factors. One major factor is the impact of respiratory diseases on patients’
compliance with oral hygiene advice. Patients with respiratory diseases may have dif-
ficulty maintaining proper oral hygiene, which can lead to an increased risk of dental
caries and periodontal disease during orthodontic treatment. Mouth breathing and
altered breathing patterns and also create malocclusions (X). Orthodontic treatment
planning must integrate preventive measures to address these implications for long-
term oral health. Furthermore, respiratory diseases can also affect the duration of
orthodontic treatment. Patients with respiratory diseases may experience prolonged
orthodontic treatment time due to factors such as increased treatment sensitivity,
reduced immune function, and potential disruptions in treatment due to respiratory
symptoms or flare-ups. Dental procedures, including orthodontic treatments, can pro-
duce aerosols, which increase the risk of transmission of acute viral respiratory tract
infections. After the coronavirus disease 2019 pandemic, the concerns regarding
 Orthodontic Treatment Outcomes and Prognosis 697

aerosols and respiratory diseases have become more significant. Orthodontic proced-
ures that involve the use of instruments like high-speed handpieces and ultrasonic
scalers can generate aerosols that may contain viral particles.
Asthma is a chronic respiratory disease that affects millions globally.39 It has been
associated with various oral conditions such as periodontal disease.40 It has also been
implicated with an increased risk of root resorption. However, others did not find a sig-
nificant association.41–43 Asthma medications can affect orthodontic treatment in
several ways. Montelukast, a medication used to manage asthma, may cause a slight
delay in orthodontic tooth movement and decreased osteoclast activity, but the differ-
ences are not statistically significant.44 Steroid inhalers can lead to oral candidiasis.45
Furthermore, genetic analyses have revealed associations between obstructive
sleep apnea (OSA)–a condition often comorbid with asthma–and cardiometabolic
health. Children diagnosed with asthma may experience more severe malocclusions
than their non-asthmatic counterparts. These malocclusions can lead to mouth
breathing patterns, which might exacerbate dental problems such as tooth decay
due to reduced saliva flow caused by mouth breathing.
Cystic fibrosis (CF) represents the most prevalent life-limiting autosomal recessive
disorder among individuals of European descent, typically manifesting in childhood.
It primarily affects the exocrine glands of the lungs, liver, pancreas, and intestines,
leading to progressive multisystem failure and disability. Oral manifestations of CF
include hypoplastic enamel and delayed tooth eruption. While tetracycline staining
of teeth was reported in the past, alternative medications are now utilized, and anti-
biotic treatment has been associated with a lower prevalence of dental disease. Given
the systemic nature of CF and its impact on respiratory health, it is essential to
consider potential implications for orthodontic treatment. Although direct evidence
on the specific effects of CF on orthodontic interventions is limited, the underlying
pathophysiology and associated complications warrant attention. Notably, individuals
with CF are prone to respiratory infections and compromised lung function due to
mucus accumulation in the airways.46
Numerous studies have underscored the link between abnormal breathing patterns,
such as mouth breathing, and alterations in craniofacial development and malocclu-
sions.47,48 The work of Guilleminault highlights how mouth breathing, often associated
with OSA, can lead to maxillary constriction and mandibular retrognathia, necessi-
tating specialized orthodontic interventions.49 Patients with respiratory disorders,
particularly those with nasal airway resistance, may encounter challenges in adapting
and tolerating to orthodontic appliances bulky headgear might be contraindicated for
sleep apnea patients, while lip bumpers can benefit mouth breathers. Beyond mouth
breathing, tongue posture significantly influences airway patency and craniofacial
development.50,51 Myofunctional therapy can be effective in improving upper airway
dimensions, potentially complementing orthodontic interventions.52 Mouth breathing
and altered breathing patterns have been linked to periodontal issues.51

ALLERGIES

The biocompatibility of orthodontic materials and their potential to elicit allergic reac-
tions have been subjects of investigation.53–55 The literature suggests a bidirectional
interaction, wherein orthodontic appliances may exacerbate allergic responses, while
allergic conditions may compromise the efficacy of orthodontic interventions.
Allergic reactions to various components of orthodontic appliances, such as nickel,
latex, or auto-polymerized acrylic resin, have been extensively documented.56,57
These reactions can lead to heightened discomfort, inflammation, and delayed healing
698 Gupta et al

and compromised treatment timelines.58 The inflammatory response associated with

allergies may also contribute to delayed tissue healing, influencing the overall success
of orthodontic interventions.59
Nickel allergy is a common concern in orthodontics, with studies suggesting a low
but existing prevalence of nickel allergy in orthodontic patients.56,60,61 The prevalence
of nickel allergy is estimated to be 11% in women and 2% in men, with sensitization to
nickel increasing due to the widespread use of jewelry containing the metal. However,
there is evidence suggesting that orthodontic treatment with nickel-containing metallic
appliances before ear piercing may reduce the likelihood of nickel allergy.61 The release
of nickel ions from metallic orthodontic appliances during treatment has been demon-
strated in both in vitro and in vivo studies, emphasizing the importance of considering
the biocompatibility of these materials.62 The immune response to nickel often mani-
fests as a type IV cell-mediated delayed hypersensitivity reaction.63 This reaction is
commonly associated with the leaching of nickel from orthodontic appliances, leading
to contact dermatitis or mucositis upon re-exposure to the metal.64 Oral clinical signs
and symptoms of nickel allergy include a range of manifestations such as a burning
sensation, gingival hyperplasia, and stomatitis with mild-to-severe erythema. Further-
more, individuals with a history of atopic dermatitis to nickel-containing metals should
be treated with caution during orthodontic treatment.54
Orthodontists should replace Ni-Ti archwires with alternative materials such as
stainless steel archwires with low nickel content, titanium molybdenum alloy, and
fiber-reinforced composite wires. Additionally, alternative nickel-free bracket mate-
rials including ceramic and polycarbonate can be used, or fixed appliances may be
substituted with plastic aligners.
The use of auto-polymerized acrylic resin in orthodontic appliances has been asso-
ciated with hypersensitivity reactions in patients.65 These reactions have been linked to
the release of toxic components, known as haptens, from the resin, including formalde-
hyde, benzyl peroxide, plasticizers such as dibutyl phthalate, and residual methyl meth-
acrylate monomer. The leaching of residual monomer into the oral environment has
been identified as a primary cause of these reactions, with concentrations of 1.5% to
4.5% in self-curing acrylic resins and 0.3% in heat-curing resins. International stan-
dards limit residual monomer levels to 4.5% for self-curing and 2.2% for heat-curing
acrylic resins.66 Residual monomer leaching from the resin into the oral environment
can cause local and systemic reactions. Studies have shown that acrylic resins, espe-
cially chemically activated ones, can be cytotoxic due to high residual monomer levels.
The cytotoxic effects of acrylic resins have been assessed through various in vitro tests,
such as the MTT test, which measures cell viability. Different polymerization methods
and the composition of acrylic resins have been found to influence their cytotoxicity.67
Additionally, the leached products from acrylic resins have been shown to affect lipid
metabolism, induce membrane alterations, and inhibit cellular growth.
The prevalence of potential type I hypersensitivity to latex is lower than 1% in the gen-
eral population, but it ranges between 6% and 12% among dental professionals.68 The
increase in allergic reactions to natural rubber latex (NRL) over the past 2 decades has
been attributed to the expanded use of latex-based gloves, particularly powdered
gloves, which serve as the primary reservoir of latex allergens.69,70 Specific guidelines
in Europe and the US have successfully reduced its incidence in high-risk populations
within the medical field.71 Additionally, orthodontic elastics used for intermaxillary
forces application are identified as another potential source of latex protein, leading
to both type I and type IV hypersensitivity reactions.72 Latex allergy is an immunoglobin
(Ig) E-mediated immediate hypersensitivity response to NRL protein, presenting with
various clinical signs such as contact urticaria, angioedema, asthma, and anaphylaxis.
 Orthodontic Treatment Outcomes and Prognosis 699

The clinical effects of latex allergy are attributable to either type I or type IV hypersen-
sitivity reactions.73
Allergies have been suggested as a potential factor associated with root resorption
in orthodontic treatment.41 Those with higher levels of IL-17, demonstrated increased
orthodontic root resorption (Shimizu and colleagues, 2013). However, statistical signif-
icance of this association was not consistent across studies.54,74–76

RENAL DISEASES

As per the Centers for Disease Control and Prevention, about 10000 children and ad-
olescents in the US are currently dealing with kidney failure and are undergoing treat-
ment through dialysis or kidney transplantation.77
Dentally, chronic kidney disease (CKD) may cause delayed tooth eruption. The eti-
ology of this is unclear but maybe due to overall impaired somatic growth. Panoramic
radiographs reveal atypical features such as a bone with a ground glass appearance
due to poor calcification, absence of lamina dura, hypercementosis, and constriction
of the dental pulp chamber.
Radiographic dental findings in CKD patients are associated with hyperparathyroid-
ism that is associated with CKD and renal osteodystrophy. Increased activity of oste-
oclasts influences all bones, encompassing the jaws and the alveolar bone.77
Orthodontists commonly encounter cases of chronic renal failure. Orthodontic treat-
ment is considered appropriate for patients with well-controlled disease. However, if
the renal failure is in an advanced stage and dialysis is imminent, it is advisable to
postpone the treatment.77
In individuals with chronic renal failure who are not dependent on dialysis, it is advis-
able for the orthodontist to confer with the patient’s physician. If the renal failure has
progressed significantly, and dialysis is on the horizon, orthodontic treatment should
be postponed.78
Renal transplant patients utilize combinations of immunosuppressant drugs,
including Azathioprine, Prednisolone, Cyclosporin, Tacrolimus, and Mycophenolate
Mofetil, to prevent graft rejection. Additionally, patients may receive calcium channel
antagonists such as Amlodipine or Nifedipine. Children who have undergone renal
transplants frequently experience drug-induced gingival overgrowth due to the pro-
longed use of these medications.78
The extent of gingival hyperplasia varies widely among individuals. Orthodontic ap-
pliances, particularly fixed ones, can elicit a significant response in the gingival tissues,
even if there is no pre-existing gingival overgrowth before orthodontic treatment. Reg-
ular visits to a hygienist are essential for these patients throughout their orthodontic
treatment.78 In some cases, there might be a recurrence of gingival overgrowth,
requiring surgical intervention during orthodontic treatment. Patients and parents
should be informed about this possibility in advance.78

LIVER DISEASES

Patients with liver diseases have high prevalence of periodontal disease. In liver
cirrhosis it ranges between 25% and 69%. Xerostomia is also another common finding
in these patients.79
Hepatitis B, C, and D are transmitted through blood and can be contracted via
contaminated sharps and droplet infection. It is crucial to treat all patients as poten-
tially infected, and universal cross-infection control measures should be implemented.
Orthodontic procedures that generate aerosols include interproximal stripping for
enamel removal, clearing residual cement after debonding, and prophylaxis.80
700 Gupta et al

MUSCULOSKELETAL PROBLEMS

Osteoporosis: It is a prevalent metabolic bone disease characterized by the progres-

sive reduction of bone density and deterioration of bone structure. While it is more
frequently observed in women post-menopause, it can also affect men. In cases of
confirmed osteoporosis in women, bisphosphonate drugs are the primary choice of
treatment.81 The administration of bisphosphonates appears to be linked with adverse
clinical outcomes, extended treatment duration, and alterations in the roots and adja-
cent tissues of orthodontic patients.80
The success of orthodontic treatment relies on osteoclastic activity, which facili-
tates tooth movement. The extent of tooth inhibition is expected to be influenced by
the potency of the osteoclastic inhibition specific to bisphosphonate and the dosage
administered at the particular site. It is presumed that inhibition of tooth movement oc-
curs to a greater extent and more rapidly with high intravenous doses compared to
lower oral doses.82
Orofacial muscles dysfunction: In individuals with orofacial dysfunction and syn-
dromes, open bite is commonly observed. Patients with open bites typically exhibit
weak orofacial muscles, anterior positioning of the tongue, mouth breathing, and an
open mouth posture. Progressive myopathies like Myotonic Dystrophy Type 1 and
Duchenne Muscular Dystrophy frequently present with malocclusions, particularly
lateral and anterior open bites.81
Ehlers-Danlos syndrome (EDS): It encompasses a group of inherited conditions
impacting the structure and function of collagen proteins, resulting in functionally
weaker or decreased production of collagen. Common features include elastic skin,
hypermobile joints, and fragile bony tissues. Dental characteristics relevant to EDS
include joint hypermobility, dystrophic scars, poor wound healing, and a tendency
to bleed excessively. In cases where the temporomandibular joint (TMJ) is notably
affected, shorter appointment durations with frequent rests and regular TMJ assess-
ments may be necessary. Certain forms of EDS can make patients more susceptible
to periodontal problems and caries due to tooth morphology. During orthodontic treat-
ment, teeth are likely to move rapidly due to collagenous laxity. There is also an
elevated risk of damaging the fragile periodontal ligament, emphasizing the need for
the use of light forces whenever possible. Additionally, there is a high potential for or-
thodontic relapse, making the consideration of both bonded and removable retainers
important.83

AUTOIMMUNE DISEASES

Diabetes Mellitus: Being aware of the oral complications associated with diabetes
mellitus, dental practitioners should take them into consideration when treating pa-
tients with DM.84 It is advisable not to proceed with orthodontic treatment for patients
with uncontrolled diabetes. In cases where the patient’s metabolic control is not
optimal (HbA1c  9%), diligent efforts should be made to enhance blood glucose con-
trol. For DM patients with well-managed medical conditions and no complications,
routine dental procedures can be carried out without specific precautions.84 Yet, there
is still an increased likelihood of gingival inflammation, likely attributed to impaired
neutrophil function. Throughout the course of treatment, orthodontists should closely
monitor the periodontal health of patients with diabetes. Additionally, scheduling
extended orthodontic appointments in the morning, following the patient’s insulin in-
jection and a regular breakfast, is recommended.78
Juvenile Idiopathic Arthritis (JIA): It is an inflammatory disease with destructive ef-
fects, primarily affecting children and leading to joint pain, swelling, and limitations in
 Orthodontic Treatment Outcomes and Prognosis 701

range-of-motion.81 More prevalent in females, JIA typically begins before the age of 16
and involves progressive destruction of articular surfaces in various joints, including
hands, wrists, fingers, toes, knees, shoulders, and elbows.81 The TMJ is affected in
45% of JIA case. Nine orthodontic issues associated with JIA include mandibular retro-
gnathia, condylar hypoplasia, a steep mandibular plane angle, open bite, antegonial
notching, increased lower face height, and skeletal class II. Many of these problems
are linked to condylar bone resorption. Facial asymmetry can result from unilateral
TMJ involvement.85 Approximately 70% of patients experience remission during
adolescence.81
In the initial stages of managing the condition, non-steroidal anti-inflammatory
drugs are employed.83 While some individuals may remain asymptomatic and can
be treated with intracapsular steroid injections, others may experience condylar hypo-
plasia, leading to a growth rotation that is both downward and backward.83
Upon achieving control over inflammation, the objective of orthodontic treatment is
to restore optimal occlusion and mandibular function. Daily mandibular physical ther-
apy, emphasizing a gradual increase in mandibular movement and the prevention of
further joint stiffness, can complement this goal. It is advised to avoid the use of heavy
class II elastics as they can exert excessive stress on the joints. The utilization of func-
tional appliances remains a topic of debate, with questions surrounding whether these
appliances amplify stress on the TMJ or act as joint protectors by relieving pressure on
the condyles. Orthognathic surgery is typically deferred until growth is complete,
except in instances of TMJ ankylosis, which necessitate earlier surgical intervention.85

SUMMARY

The number of medically compromised patients seeking orthodontic care is increasing

and this trend is likely to continue. While orthodontic therapy is typically viewed as be-
ing of low risk compared to more invasive dental procedures, specific orthodontic
treatments could be potentially harmful to certain patient populations. Continuous ed-
ucation and appropriate intervention studies are needed to reduce the complication of
these hazards. Orthodontists must maintain up-to-date measures in respect to
dealing with newer modes of orthodontic practice, developments in orthodontic ma-
terials, as well as be aware of personal health and management for special medical
care for this professional group. It is imperative to exercise prevention as a most
important aspect of risk management.
Orthodontists must understand these hazards and their outcome, to ensure that we
can be successful practitioners.

CLINICS CARE POINTS

Malignancies
 Cancer therapies can compromise the mechanical properties of oral tissues, leading to
increased susceptibility to trauma and delayed healing.
 Orthodontic forces may need to be modified to accommodate compromised tissue integrity.
Neurological disorders
Multiple sclerosis (MS)
 Patients with MS are almost universally infected with Epstein-Barr virus (EBV).
 Symptoms of MS may impact a patient ability to maintain oral hygiene, attend dental
appointments, or undergo orthodontic procedures.
702 Gupta et al

Epilepsy
 Patients should continue their antiepileptic medication as prescribed and should not be
overly fatigued during appointments.
 The potential side effects of antiepileptic medications, such as gingival overgrowth
associated with phenytoin, should be monitored.
 Removable appliances should be used with caution due to the risk of dislodgement during a
seizure.
Attention-deficit/hyperactivity disorder (ADHD)
 Children with ADHD exhibit a higher prevalence of caries and periodontal problems thereby
requiring strict oral hygiene maintenance.
Respiratory Diseases
Asthma
 Montelukast, a medication used to manage asthma, may cause a slight delay in orthodontic
tooth movement.
 Steroid inhalers can lead to oral candidiasis.
Cystic Fibrosis (CF)
 Oral manifestations of CF include hypoplastic enamel and delayed tooth eruption.
Allergies
 In patients with Nickel allergies, replace Ni-Ti arch wires with alternative materials such as
stainless steel with low nickel content, titanium molybdenum alloy, fiber-reinforced
composite wires.
Renal diseases
 Chronic kidney disease may cause delayed tooth eruption.
 If the renal failure is in an advanced stage and dialysis is imminent, it is advisable to postpone
orthodontic treatment.
Liver diseases
 Patients with liver diseases have high prevalence of periodontal disease and also xerostomia.
Musculoskeletal problems
 In patients with Ehler Danlos syndrome, where the temporomandibular joint (TMJ) is notably
affected, shorter appointment durations with frequent rests and regular TMJ assessments
may be necessary.

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