ORTHODONTIC MANAGEMENT OF

MEDICALLY COMPROMISED
PATIENTS

Dr. ANMOL GOEL

VSDCH

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 CONTENTS
Introduction
Definition
Infective endocarditis
Metabolic disorders
Diabetes
Adrenal insufficiency
Haematological disorders
Bleeding tendencies
Malignancies
Autoimmune
Juvenile rheumatoid
2 arthiitis
 Respiratory disease
Asthma
Allergies
Latex
Nickel
Nervous system disorders
Epilepsy
Liver disorders
Immunocompromised states
Others
Effect of drugs on orthodontic treatment
Conclusion
References
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 INTRODUCTION

A pilot study performed in 2002 of several orthodontic

practices revealed that more than 25% of patients
seeking orthodontic therapy had some medical
diagnosis that potentially impacted their care.

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5
INFECTIVE ENDOCARDITIS

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 INFECTIVE ENDOCARDITIS

• Infective endocarditis (IE) is a disease in which microorganisms

colonise the damaged endocardium or heart valves.

• The organisms most commonly encountered in IE are alpha -

hemolytic streptococci (e.g., Streptococcus viridans). However,
nonstreptococcal organisms often found in the periodontal
pocket have been increasingly implicated, including Eikenella
corrodens, Actinobacillus actinomycetemcomitans,
Capnocytophaga, and Lactoba-cillus species.

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 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 bacteraemia while manipulating
orthodontic bands
• McLaughlin et al 1996 reported bacteraemia in 10% patients while
fitting orthodontic bands

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9
WHO IS AT RISK?

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 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

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 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.
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• 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

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14
METABOLIC DISORDERS

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 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).

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 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 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.

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DIABETIC PATIENT AND
DENTAL TREATMENT
• Identify diabetic patients –
• Xerostomia
• Candidiasis
• Glossopyrosis
• Recurrent oral infections
• Ketone breath
• Poor periodontal health
• Multiple carious teeth

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 Factors responsible for these oral manifestations-
• Abnormal collagen metabolism
• Altered protein metabolism due to hyperglycemia
• Impaired neutrophil chemotaxis and macrophage function

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 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% chlorhexidine 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

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• 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.

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 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
oral carbohydrate such as regular cola, table sugar, or even a spoonful
of honey to raise blood glucose levels.

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 Osteoporosis
Orthodontic treatment must consider problems such as bone
loss, retention instability, and temporomandibular dysfunction.
Estrogen decreases the rate of tooth movement.
Use of Bisphosphonates can affect orthodontic treatment by
delaying tooth eruption, inhibited tooth movement, impaired
bone healing, and by causing BP-induced (ORN) of the jaws.
Extraction protocol and use of temporary anchorage devices
should be avoided.
BP inhibits osteoclasts, decreases microcirculation and thus
impedes tooth movement.

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 Thyroid and Parathyroid Disorders
Orthodontic considerations
Orthodontic therapy requires minimal alterations in the patient
with adequately managed thyroid disease.
In hyperthyroidism enlarged tongue may pose problem during
treatment.
The bone turnover can influence orthodontic treatment. High
bone turnover (i.e., hyperthyroidism) can increase the amount
of tooth movement compared with the normal or low bone
turnover state in adult patients.
Low bone turnover (i.e., hypothyroidism) can result more root
resorption, suggesting that in subjects where a decreased
bone turnover rate is expected, the risk of root resorption
could be increased.

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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.

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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
anaesthesia may help to minimise 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.
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RESPIRATORY DISORDERS

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 ASTHMA
Typical oral health conditions in asthma:
Greater rate of caries development than 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.
McNab and colleagues compared the incidence and severity of
external root resorption following fixed orthodontic therapy the
incidence of external apical root resorption was elevated in the
asthmatic population, the severity of resorption was the same
between groups.

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 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.
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.

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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 as ‘asthma trigger', so the orthodontist should
reduce the stress level of the patient.
Oxygen and bronchodilator should be available during treatment.

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During treatment:
• 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, ketorolac, ibuprofen and
naproxen sodium should be avoided after banding
and bonding. In such cases, choice of analgesic is
acetaminophen.
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 ACUTE ASTHMATIC 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
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 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.
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 • 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.

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 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
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LATEXFREEPRODUCTS

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 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.

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 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

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 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

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 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.

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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
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 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.

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 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 epileptic(AEDs) medication
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.
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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

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 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
Do not 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, and keep the patient supine with legs
elevated.
If the seizure activity lasts beyond 5 minutes it is imperative to seek
emergency help.
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 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 tissues 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 and lead to complete
bony Ankylosis.

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 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

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48
 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 minimise caries.
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HAEMATOLOGICAL DISORDERS

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 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
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 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.
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 Vitamin K Deficiency
Deficiency in the first trimester results in maxillonasal hypoplasia in
neonate with resulting facial and orthodontic implications.

Maxillonasal hypoplasia has been classified on the basis of facial

features as Binder's syndrome. It is characterized by broad flat nose,
horizontal nostril, short columella, broad philtrum, pouting upper lip,
marked groove at the nasolabial junction, and concave profile.

Surgical treatment for Binder's syndrome is usually performed by

plastic surgeons and is limited to nasal dorsum reconstruction,
elevation of the tip of the nose and lengthening of the nasal dorsum.

Surgical correction of nasal and maxillary abnormalities is usually

followed by orthodontic treatment. Planning the orthodontic treatment
depends on the severity of the malocclusion.

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 Sickle cell Anemia
Sickle cell disease is a commonly used term for designating a
family of various blood disorders characterized by the presence
of hemoglobin S (Hb-SS).

The increased number of malocclusions in patients with sickle

cell disease can be related to muscular imbalance, absence of
labial sealing, or changes in the osseous base, thus leading to
orthodontic intervention.

Malocclusion can be observed because of maxillary protrusion

and retrusion of the anterior teeth. The former can be associated
with the increased medullary activity and marked maxillary
growth. In addition, lip pressure caused by overjet results in
retrusion of the incisor teeth.

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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
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HAEMATOLOGICAL
MALIGNANCIES

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• More than 40% paediatric malignancies are hematological
either leukaemia or lymphoma.
• Oropharyngeal lesion can be the initial signs in 10% of
acute leukaemia.
• 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.

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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 moisturisers 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 treatment
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 RENAL FAILURE

Chronic renal failure may be due to a variety of causes

which lead to loss of kidney function. Treatment involves
dietary restriction 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.

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 ORTHODONTIC CONSIDERATIONS
Those who are not dialysis dependant- orthodontic treatment must
be started only if the disease is well controlled and after the
physician’s consent
For dialysis dependant patients 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
Removable appliances should be avoided as they may fail to fit
owing to hyperplastic gingiva

60
 Extraction should be done cautiously in such patients.
demineralization.
Renal insufficiency is considered a risk condition for IE if the
patient does not have a good control of the disease.
Antibiotic prophylaxis should be consider in hemodialyzed
patients who were undergoing an invasive dental
procedure.
During hemodialysis, the patient's blood is anticoagulated with
heparin to facilitate blood transit. For this reason, dental
treatments with a risk of bleeding must not be performed on the
day of hemodialysis.

Appointments should be scheduled on non-dialysis days. The day

after dialysis is the optimum time for treatment for surgical
procedures as platelet function will be optimal and the effect of
heparin will have worn off.

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 LIVER DISEASES

Liver Diseases 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.

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 HEPATITIS B
Hepatitis B is a worldwide health problem, with an estimated
400 million carriers of the virus.
1.53% of all patients reporting to the dental clinic - 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.
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 ORTHODONTIC
CONSIDERATIONS

•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 transmit 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.
64
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.
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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%

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 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.

67
• 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

68
• 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. 69
 Down’s Syndrome
The primary skeletal abnormality affecting the orofacial
structures in Down syndrome is an underdevelopment of
the midfacial region. The bridge of the nose, bones of the
midface and maxilla are relatively smaller in size;
this causes a prognathic class III occlusal relationship,
which contributes to an open bite.
Individuals with Down syndrome have delayed eruption
pattern. There is usually congenitally missing teeth and
they can have unusually shaped teeth.

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Children with heart defects who are undergoing dental
procedures should be given antibiotic prophylaxis against
subacute bacterial endocarditis.

Reduced muscle tone causes less efficient chewing and natural

cleansing of the teeth hence oral hygiene instruction should be
given in every visit.

Seizures occur in 5-10% of children with Down syndrome.

Seizures are diagnosed and treated similarly in children with
and children without Down syndrome.

Impressions using quick-set materials with fun flavors should be

used as these may reduce the tendency for activation of the
more sensitive gag reflex frequently experienced with Down
syndrome patients.
High-memory wires allow a longer activation interval between
appointments.
Self-ligating brackets allow a more patient-friendly activation
appointment.
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 AUTISM
The main challenge to the orthodontic team may be the reduced
ability of autistic patients to communicate and relate to others.

The first several visits are directed towards raising the patient's
confidence and determining the maximum level of compliance
that is achievable.
An estimate of the most suitable way (behaviour management,
sedation or general anaesthesia (GA)) to perform the more
difficult procedures, such as impressions or bracket bonding may
be made.
Pain and anxiety control during orthodontic treatment of the
autistic child may be divided into conscious methods (such as
oral, intramuscular, inhalation with nitrous oxide and oxygen, and
intravenous sedation) and unconscious methods (intravenous or
inhalation deep sedation and GA ) with endotracheal intubation.

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Patient should be treated in a quiet, shielded single
operatory versus an open-bay arrangement, with
reduced decoration and dimmed lights.
Procedures such as tell-show-do, voice control, and
positive reinforcement are effective with children.
The effectiveness of reinforcers can vary among
children with autism spectrum disorder (ASD).
Many children may find reinforcing value in typical,
age-appropriate reinforcers such as praise, stickers or
video clips while other children's behavior might be
reinforced by engaging in self-stimulatory behaviors
(for example, hand flapping, or self-talk)

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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
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 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.

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 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

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 • 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) corticosteroids
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
impinge on the gingiva and dental calculus plaque and mouth-
breathing aggravates gingival hyperplasia.
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 CONCLUSION

• An orthodontist needs to recognise 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 minimised.
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
minimise physical damage and to maximise treatment outcome.

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 REFERENCES
Orthodontic Management of Syndromic Patients- A Review .Ishan Goyal , Naveen
Bansal.Acta Scientific Dental Sciences (ISSN: 2581-4893) .September 2018
Oral health management considerations for patients with sickle cell disease Nadia
Kawar .Disease-a-Month(2018)
Burden D, Mullally B, Sandler J. Orthodontic treatment of patients with medical
disorders.Eur J Orthod. 2001 Aug;23(4):363-72.
Craniofacial and Dental Manifestations of Melnick–Needles Syndrome: Literature
Review and Orthodontic Management .Case Reports in Pediatrics
Volume 2018 .Dorota Kustrzycka .
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 indental 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.

81
Orthodontic consideration with patients with bleeding disorders.International journal of
oral rehabilitation.volume 9 2018.Vaidehi Arekar

Sanders AJ, Dodge NN: Managing 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 endocrinedisorders. J Clin
Exp Dent. 2010;2(4):e196-203.
JenaAK, Duggal R, Mathur VP, Prakash H, orthodontic care for medically compromised
patients. J ind orthod society 2004; 37: 160-171

82
The dental team and latex hypersensitivity.Journal of American dental
association.February 1999

Chronic congenital systemic disorder- a hurdle in orthodontic treatment

plans: Meta analysis Siddharth Sonwane .Int J Med Res Health Sci. 2016,
5(6):239-247

Orthodontic Considerations in the Diabetic Patient Luc Bensch.

Seminars in Orthodontics 10:252-258 . 2004

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