medically compromised orthodontic patients by almuzian

University of Glasgow

2013

Orthodontic Management of Medically Compromised Patients

Mohammed Almuzian

Orthodontic Management of Medically Compromised Patients

Key article Burden paper in 2001

BOS guidelines regarding medical guidance

A medical history should be comprehensive

The medical history should be kept safely with the patient’s record

A patient’s medical history should be 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 or specialist for additional

treatment.

A competent person who is likely to be aware of the patient’s full

medical details should give details of the medical history. This may be

the patient, parent or carer.

If using a medical history questionnaire that patients/parents

complete on their own, the orthodontist should always check the

accuracy of answers.

For some patients e.g. with complex or serious medical problems,

it would be prudent to check details of the medical history with the

patient’s doctor (with the patient’s consent) and to ask for appropriate

guidance about management.

Mohammed Almuzian, University of Glasgow, 2013 1

A. Infective Endocarditis

Implications for orthodontic therapy:

1. Its incidence does not appear to be higher during orthodontic

treatment. However, only 4 cases have been reported in relation to

orthodontics.

2. But bacteraemia can be increased by plaque accumulation which in

turn increased with orthodontic appliances.

3. NICE guidelines 2008 (no Antibiotic nor chlorohexidine mouth are

given to dental patient) except very high risk patients.

4.

Procedures that can cause bacteraemia:

1. Impression

2. Separator placements (greatest bacteraemia)

3. Fitting or removing bands

4. Surgical exposure of teeth.

Management according to BOS

1. Informed consent – patient needs to know of any increased risk

and should be informed about the uselessness of AB.

2. Need high standard OH with daily antimicrobial M/W – (eg.

chlorhexidene 0.2%) 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 – where possible

(exceptions are RME, HG, QH)

4. Un-erupted teeth - avoid bonding w closed eruption.

5. Antibiotic prophylaxis

In medium risk cases AB is not used.

In high risk cases all procedures liable to cause bacteraemia should be

covered by antibiotic prophylaxis. Note that antibiotic administration is

not without risk and should only be used where a clear indication exists.

6. Antibiotic prophylaxis regime

1. No Penicillin allergy

0-5 years Amoxycillin oral 750mg 1 hr pre-op

5-10 years Amoxycillin oral 1.5g 1 hr pre-op

10+ years Amoxycillin oral 3g 1 hr pre-op

2. Penicillin allergy or penicillin more than once in last month

0-5 years Clindamycin oral 100mg 1 hr pre-op

5-10 years Clindamycin oral 300mg 1 hr pre-op

10+ years Clindamycin oral 600mg 1 hr pre-op

3. Note that an additional post-op dose of antibiotic is no longer

recommended.


B. Prosthetic joints

1. No AB prophylaxis needed

C. CNS

Hydocephalus and Cerebrospinal shunts

ABP may be needed – consult specialist

Seizure Disorders: eg. Epilepsy (eg. Grand Mal)

1. Anti-epileptic drugs should be taken regularly.

2. Sedation may be indicated in stress induced procedure like surgical

exposure.

3. For patients with recurrent hyperplasia, the patient’s physician

should be contacted to discuss alternative medication

4. If an individual having a class II Division I incisor relationship

experiences an aura before a seizure, he or she should carry a soft mouth

guard with palatal coverage and extending into the buccal sulci to use at

such times

5. Avoid removable if epilepsy poorly controlled

6. Small low profile brackets are recommended.

7. Bands are avoided.

8. 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.


9. Essix based retainers should be relieved around the gingival

margins to maintain alignment.

10. Bonded retainers are avoided in patients at risk of DIGO

D. Pregnancy

1. Avoid X-rays or drug therapy, especially in first trimester.

2. Avoid supine position in late pregnancy.

3. Good OH

E. Latex allergy

Prevalence: 1% of population

Who at risk?

1. Patient with allergic rhinitis,

2. Asthmatic patient

3. Eczema patient

4. Patient hypersensitive to certain food

5. Atopic patient

6. Patients with spina bifida. Spina bifida (Latin: "split spine")

is a developmental congenital disorder caused by the incomplete closing

of the embryonic neural tube. Some vertebrae overlying the spinal cord

are not fully formed and remain unfused and open. 68% of children with

spina bifida have an allergy to latex

7. Pts with urogenital anomalies

8. Patient with multiple previous operation

9. Healthcare professional


10. Latex industry worker

Management

1. Definitive diagnosis

Patch testing

Pin prick testing,

Blood test (immunoassay)

2. Staff training and communication: Staff should be aware of

emergency protocols for dealing with anaphylactic reactions and

auxiliary staff should be aware of the diagnosis.

3. Appointment and surgery management: Appointments should be

scheduled for the early morning with use of a latex-screened area to

segregate latex-free products to avoid contamination.

4. Appliance design and handling

Latex free gloves.

The use of elastomeric ties could be avoided with use of self-ligating

brackets.

Space closure should be undertaken with nickel– titanium coils.

Where inter-maxillary elastics are required, latex-free elastics can be

used, although they are subject to greater force degradation.

Types of reaction to Latex

1. Type I hypersensitivity reaction

2. Type IV hypersensitivity reaction (Allergic contact dermatitis)


F. Nickel allergy

Nickel induces a contact dermatitis, which is a Type IV delayed

hypersensitivity immune response, cell-mediated by T lymphocytes.

1. More common in girls than boys

Girls (30%), in boys (3%) in Finnish

in adolescents with pierced ears (31%) than those without ear

piercings (2%) (Bass et al., 1993) .

10 % in female and 3% in male (Nelsen and Menn 1993)

2. The use of nickel containing jewellery and the increased popularity

of body piercings, in particular intra-oral piercings means that many

patients may have been sensitized to nickel by the time they visit an

orthodontist. As a result, this allergy may become an increasingly

common presentation to the orthodontist.

3. Nickel hypersensitivity has also been found to be higher in

asthmatic patients

4. More serious if contact the skin than mucosa, 5 - 12 times the

concentration of nickel required to provoke mucosal lesions compared

with skin lesions

5. Nickel is found in arch wires, bands, brackets and headgear, with

stainless steel containing nickel in the ratio of 18:8, with 8 referring to

the level of nickel.

Signs and symptoms of nickel allergy

1. For the gingivae:

Gingivitis in the absence of plaque

Gingival hyperplasia

2. For the tongue:


Burning sensation in the mouth

Metallic taste

Numbness/tingling sensation

Soreness of the side of the tongue

3. For the lip:

Labial swelling

Angular cheilitis

Labial desquamation

4. Extra-oral signs and symptoms can include localised dermatitis in

sites of prolonged skin contact with nickel-containing objects, for

example, headgear studs. This can present as a maculopapular skin rash

or vasculitis-like skin lesions.

Management according to BOS guidelines

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 the patient monitored

carefully to assess a reaction.

Patch testing using 5% nickel sulphate in a petroleum jelly substrate.

Pin prick testing,

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

Plastic aligners

b. Nickel free archwires

Titanium Molybdenum alloy (TMA) archwires

Fibre-reinforced composite archwires

Pure Titanium archwires

Gold plated archwires

c. Extra oral appliances

For nickel sensitive patients, exposed metalwork should be covered

with tape or plasters or headgear use discontinued. Plastic coated

headgear studs are also available.

G. Diabetes mellitus

Diabetes mellitus (DM) is a metabolic disorder diagnosed in

approximately 3% to 4% of the population.

The disease is characterized by chronic hyperglycemia caused by a

deficient insulin management.

Two main types of DM exist: type 1 DM, being a total deficiency

in insulin secretion, and type 2 DM, which is a combination of

resistance to insulin action and inadequate compensatory insulin

secretion

Orthodontic considerations in patients with DM

1. Orthodontic treatment is avoided in patients with poorly controlled

DM


2. Morning appointments are preferable

3. If longer sessions are scheduled then patient is advised to take meal

and medication

4. Periodontal health is to be evaluated regularly.

5. Strict oral hygiene measures are adopted.

6. Orthodontic forces are kept to minimum because there is

weakening of periodontal ligament and osseous regeneration; Diabetic

related peripheral microangiopathy can affect the peripheral vascular

supply, resulting in unexplained toothache, tenderness to percussion and

even loss of vitality.

7. The orthodontic team should be trained to deal with diabetic

emergencies

H. Juvenile Idiopathic Arthritis or Still’s disease

Orthodontic considerations in patients with JIA

Limiting mouth opening might cause difficulty in brushing, so OH

should be supported with additional regime

A bite splint can be provided to unload the joint during any acute

periods of inflammation.

A distracted splint has also been suggested to modify mandibular

growth in the same way as conventional functional appliances.

The use of functional appliances in patients is a controversial 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,.


Mandibular surgery to advance it should be avoided

I. Renal problems

OH

Reduce treatment

Avoid exo

Avoid ulceration and sharp edges

Light force

J. Rickets

Rickets in children and osteomalacia in adults are the classic

manifestations of profound vitamin D deficiency.

The child has retarded growth.

High risk of OIIRR

Impaired growth may influence our treatment plan in case of

functional appliances.

Orthodontic forces are kept to minimum.

K. Osteoporosis

Osteoporosis is a common progressive metabolic bone disease that

decreases bone density and deterioration of bone structure.

Osteoporosis can develop as a primary disorder or secondarily due to

some other factor.

It is most common in women after menopause, but may develop in

men.


Orthodontic considerations in patients with Osteoporosis

Patients on oral BPs are at a lower risk of bisphosphonates induced

osteoradionecrosis (ONJ) or osteoclastic inhibition. This risk is about

0.5% in patient taking oral Bp and 96% in patient on IV Bps. The

mandible is at higher risk than maxilla.

Use of bisphosphonates

Osteoporosis in post-menopausal women

Paget’s disease and bone resorption caused by malignant osteolytic

lesions

Childhood malignancy

Potential future use of BP

Reinforce anchorage

Reduce their relapse potential after alignment or maxillary

expansion

Decrease the tendency for root resorption during orthodontic

treatment

Recommendation

1. Patient had treated previously with high dose, previous or

current IV BP

Consult GP and avoid treatment

2. Patient had treated previously or currently with low dose


Consult treatment and start considering the following:

A. Consider the half life time and accumulative effect of BP

B. Patient should be carefully consented, including the higher risks of

ONJ

C. Treatment should initially be on a non-extraction

D. Compromised treatment preferred

E. Short treatment

F. Complex orthodontic treatment plans should only be initiated after

the response to orthodontic forces has been established.

G. Treatment should be discontinued if teeth respond poorly to

orthodontic force application. Signs of poor response to orthodontic

force application include slow or no movement of teeth, excessive

mobility, as well as radiographic evidence of sclerosis around teeth or

other abnormal radiographic changes in the periodontal ligament space.

3. Patient will be treated by BP (try to end treatment as soon as

possible)

Krieger 2013 in systematic review show no correlation in low dose

or short BP treatment

L. Blood borne viruses (Hepatitis B, C, D and G, HIV)

All patients are treated as though they are infected and universal cross-

infection control precautions are to be followed


All members of the team must be immunized against HBV and should

get serological test done once in three months.

Follow up and booster dose are done regularly

One should wear heavy utility gloves and personal protective

equipment during the decontamination procedure

Increase tendency to infection and ulceration

Increase tendency to bone resorption because of the hepatic

malfunctioning

M. Inherited coagulopathies – deficiencies in clotting factors

Implication

Bleeding tendency,

Infection risk,

Anaemia risk

Management

1. Medically:

Consult with patient’s haematologist before any surgical procedure to

check patient's Hepatitis and HIV status.

Replace missing factors factor VIII

Correct with platelet transfusion immediately prior to surgery so that

platelet levels are at least 50 x 109/l

Anti-fibrinolytics should be used post-surgery

2. General dental management:

If only 1-2 teeth are extracted, an INR < 3.5 is acceptable, with local

control of haemostasis

Avoid regional nerve blocks,


Avoid drugs that increase bleeding tendency (e.g. aspirin) or cause

gastric bleeding (e.g. NSAID).

Be careful in prescribing analgesia and other drugs since Warfarin

interacts with other drugs e.g. aspirin, NSAID, metronidazole,

erythromycin, cephalosporins and tetracyclines

3. Orthodontically:

Self-ligating brackets are preferable to conventional brackets.

Archwires are secured with elastomeric modules instead of wire

ligature

A Vacuum formed aligners may be the appliances of choice for

selected malocclusions.

N. Sickle cell anaemia

This is a genetic disorder that is characterized by a haemoglobin gene

mutation (HbS as opposed to HbA).

Orthodontic considerations in patients withs sickle cell anaemia

Good oral

Long treatment duration to restore the regional microcirculation.

Emotional stress is avoided

The surgery is well ventilated and avoid EOA which compromise the

airway

An Extraction is contraindicated to treatment and if extractions are

necessary they are best carried out in a hospital by a maxillofacial

surgeon under complete medical care

General anaesthetics for elective procedures are contraindicated and

hence no orthognathic surgery is recommended


O. Asthma

Episodic narrowing of the airways passages that results in breathing

difficulties and wheezing.

Orthodontic considerations for patients with respiratory disorders

The patient’s physician is contacted before the treatment is

commenced.

First goal is to prevent acute asthmatic attacks so that, the orthodontist

must ensure that patient is carrying inhaler with them and avoidance of

the trigger factors

Patients with a history of asthma seem to be at a high risk for

developing excessive root resorption during treatment. This emphasizes

the prescription of low forces for these patients.

Pt who use oral inhaler might develop candidial infection and

recommendation to gargles after inhaler is requested.

The following steps should be taken to manage an acute asthmatic

attack in the dental office:

1. Discontinue the dental procedure and allow the patient to sit or lie

down in a comfortable position

2. Keep the airway open and administer Beta2-agonists with inhaler or

nebulizer

3. Administer oxygen via face mask nasal hood, or cannula

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)


P. Corticosteroids

Normal management except if the patients who have taken more than 10

mg prednisolone daily (or equivalent) within 3 months of surgery: A

suitable regimen for corticosteroid replacement before surgery with

The usual oral corticosteroid dose on the morning of surgery

Or hydrocortisone 25-50mg IV at induction.

Q. Oral contraceptives

Antibiotic therapy can reduce effectiveness of the pill

Always warn

R. Malignancy

1. Orthodontist may play an important role during initial diagnosis

2. Patient currently suffers from malignancy:

I. As orthodontic treatment is an elective procedure, orthodontic

treatment is not advisable.

II. Patient who received chemo or radiotherapy are at risk of:

Short root

Hypodontia

Malformed teeth

Delayed dental development

3. If orthodontic treatment has been already started

The orthodontist should contact the patient's physician possible for

prognosis.


As the time of diagnosis of malignancy is very stressful for the patient

and family, orthodontist should be aware of its psychological

implications.

Consider the effect of chemotherapy which can lead to opportunistic

infection and subsequent severe complications. It is advisable to remove

all orthodontic fixed appliances before starting chemotherapy as a safety

procedure.

To counter xerostomia during cancer therapy use of sugar free chewing

gum, candy, saliva substitutes, frequent sipping of water, and/or

moisturizers is recommended.

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.

American Academy of Pediatric Dentistry recommends following

strategy to provide orthodontic care for patient with dental sequelae.

1. Simple treatment

2. Quick treatment

3. Low force

4. Upper jaw treatment only (Lower jaw should not be treated).

S. Cystic fibrosis

a condition which is hereditary and associated with loss of exocrine

gland leading to dry non-productive cough and serious lung infection

Management

Consult the physician


Good OH bec of dryness associated with the affected salivary glands

Avoid GA and extraction

Short compromised treatment

Cerebral palsy

• Good motivation and oral hygiene

• Keep treatment simple

• Use URA if possible

• Sedation can be used to ease treatment

The end………………………….


medically compromised orthodontic patients by almuzian

Health & Medicine